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5/18/2021 1 HPS Alliance Members Only Home Health Webinar Series 2021 Presenter: Melinda A. Gaboury, COS-C Home Health Medical Review Denials & How to Avoid Them May 20, 2021 Home Health Medical Review Levels of Medical Review that are active for Home Health: Post Payment Additional Development Requests (ADR) by Medicare MAC Recovery Audit Contractor (RAC) Unified Program Integrity Contractor (UPIC) Supplemental Medical Review Contractor (SMRC) Office of Inspector General (OIG) Targeted Probe & Educate (TPE) – not currently active, expected to return following the expiration of the Public Health Emergency. 2 1 2

Presenter: Melinda A. Gaboury, COS-C

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5/18/2021

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HPS Alliance Members Only Home Health Webinar Series ‐ 2021

Presenter: Melinda A. Gaboury, COS-C

Home Health Medical Review Denials & How to Avoid Them

May 20, 2021

Home Health Medical Review

Levels of Medical Review that are active for Home Health:◦ Post Payment Additional Development Requests (ADR) by Medicare MAC

◦ Recovery Audit Contractor (RAC)

◦ Unified Program Integrity Contractor (UPIC)

◦ Supplemental Medical Review Contractor (SMRC)

◦ Office of Inspector General (OIG)

◦ Targeted Probe & Educate (TPE) – not currently active, expected to return following the expiration of the Public Health Emergency.

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What does a Recovery Audit Contractor (RAC) do?

RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments

What does a Unified Program Integrity Contractor (UPIC) do?

UPICs perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPIC’s perform integrity related activities associated with• Medicare Part A & B, Durable Medical Equipment (DME),

• Home Health and Hospice (HH+H), Medicaid, and

• The Medicare-Medicaid data match program (Medi-Medi).

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Home Health Medical Review

What does a Supplemental Medical Review Contractor (SMRC) do?

The Centers for Medicare & Medicaid Services (CMS) contracts with a Supplemental Medical Review Contractor (SMRC) to help lower improper payment rates and protect the Medicare Trust Fund. The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. The focus of the medical reviews may include vulnerabilities identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and Federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects to protect the Medicare Trust Fund.

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Home Health Medical Review

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What does Office of Inspector General (OIG) do?

The Medicare hospice program is an important benefit for beneficiaries and their families at the end of life. However, OIG and others have identified vulnerabilities in payment, compliance, and oversight as well as quality-of-care concerns, which can have significant consequences both for beneficiaries and for the program. We will summarize OIG evaluations, audits, and investigative work on Medicare hospices and highlight key recommendations for protecting beneficiaries and improving the program.

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Home Health Medical Review

TARGETED PROBE AND EDUCATE

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Additional Development Request

An Additional Development Request (ADR) is generated by a Medicare MAC Medical Review Department to request a provider's medical record documentation for a specific claim. Claims are reviewed to ensure compliance with Medicare's coverage, coding, payment and billing policies. 

When a claim is selected for an ADR, the claim is moved to the Fiscal Intermediary Standard System (FISS) status/location S B6001.

Some Post Payment reviews are currently being done during the Public Health Emergency ‐ ‐the content of response is the same.

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MAC/Contractors will select the topics for review based upon existing data analysis procedures.

Provider nonresponse to medical records requests will count as an error.  

RECEIPT OF DOCUMENTATION (if by the MAC)– When your documentation has been received the claim is moved from status/location S B6001 to S M50MR for review. Providers can monitor the S M50MR status/location in FISS, to verify that their documentation has been received. Confirmation of receipt is also provided when using to submit your documentation.

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Additional Development Request

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CMS Review Schedule

REVIEW OF DOCUMENTATION – A nurse reviewer will examine the medical records submitted to ensure the technical components (OASIS, certifications, election statement, etc.) are met, and that medical necessity is supported. MAC has 60 days from the date the documentation is received to review the documentation, unless this is a Targeted Probe & Educate Review, which only allows 30 days for the review.  

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Palmetto GBA Results

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Palmetto GBA Results

Top 5 Denials

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#1 Denial – Face‐to‐Face Requirements Not Met

#1 Denial – Face‐to‐Face Requirements Not Met

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#1 Denial – Face‐to‐Face Requirements Not Met

#2 Denial – Plan of Care Issues

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#2 Denial – Plan of Care Issues

#2 Denial – Plan of Care Issues

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#3 Denial – Documentation of Services Billed

#4 Denial – Care Exceeded Physician’s Orders

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#5 Denial – Medical Necessity 

#5 Denial – Medical Necessity 

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#5 Denial – Medical Necessity 

#5 Denial – Medical Necessity 

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#5 Denial – Medical Necessity 

Home Health PEPPERP Program for 

E Evaluating 

P Payment 

P Patterns 

E Electronic 

R Report

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Target areas – services and/or discharges considered vulnerable to improper payments

Provider specific ◦ National◦ State◦ MAC jurisdiction

Annual release – July 2021 ‐ Update

Home Health PEPPER

HHA Improper Payment Risks

PEPPER does not identify improper payments.

HHAs can be at risk for improper payments.

Target areas were identified based on review of the HHA PPS,review of studies related to improper payments, analysis of claimsdata and coordination with CMS subject matter experts.

Home Health PEPPER

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Target Area Target Area Definition

Average Case Mix Numerator (N): sum of case mix weight for all episodes paid to the HHAduring the report period, excluding LUPAs (identified by Part A NCH HHALUPA code) and PEPs (identified as patient discharge status code equal to ‘06’)

Denominator (D): count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs

Note: reported as a rate, not a percent

Average Number of Episodes

N: count of episodes paid to the HHA

D: count of unique beneficiaries served by the HHA

Note: reported as a rate, not a percent

Target Area Target Area Definition

Episodes with 5 or 6 Visits

N: count of episodes with 5 or 6 visits paid to the HHA

D: count of episodes paid to the HHA

Non‐LUPA Payments N: count of episodes paid to the HHA that did not have a LUPA payment

D: count of episodes paid to the HHA

High Therapy Utilization Episodes

N: count of episodes with 20+ therapy visits paid to the HHA (first digit of HHRG equal to ‘5’)

D: count of episodes paid to the HHA

Target Area Target Area Definition

Outlier Payments N: dollar amount of outlier payments (identified by the amount where Value Code equal to ’17’) for episodes paid to the HHA

D: dollar amount of total payments for episodes paid to the HHA

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Home Health Agency PEPPERVisit PEPPERresources.org

Compare Targets Report, Four Quarters Ending Q4 CY 2015

The Compare Targets Report displays statistics for target areas that have reportable data (11+ target count) in the most recent time period. Percentiles indicate how a home health agency's target area percent/rate compares to the target area percents/rates for all home health agencies in the respective comparison group. For example, if a home health agency's national percentile (see below) is 80.0, 80% of the home health agencies in the nation have a lower percent/rate value than that home health agency. The home health agency's Medicare Administrative Contractor (MAC) jurisdiction percentile and the state percentile values (if displayed) should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target area indicate that the home health agency may be at a higher risk for improper Medicare payments. The greater the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area. 

Target DescriptionTarget Count/  

AmountPercent/Ra

te

Home Health Agency National %ile

Home Health Agency Jurisdict. %ile

Home Health Agency 

State %ile Sum of Payments

Average Case Mix Proportion of the sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs and PEPs, to the count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs

296 1.14 77.1 78.0 74.0 Not Calculated

Average Number of Episodes

Proportion of the count of episodes paid to the HHA during the report period, to the count of unique beneficiaries served by the HHA during the report period

284 1.30 13.9 7.6 10.6 $753,471

Non‐LUPA Payments

Proportion of the count of episodes paid to the HHA that did not have a LUPA payment during the report period, to the count of episodes paid to the HHA during the report period

264 93.0% 44.9 34.8 81.7 $747,540

High Therapy Utilization Episodes

Proportion of the count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to ‘5’), to the count of episodes paid to the HHA during the report period

22 7.7% 51.6 49.0 44.2 $111,702

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Thank You For Participating! 

[email protected]

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