targeted probe and educate hca senior financial managers forum
TRANSCRIPT
Home Health
Targeted Probe and Educate
HCA Senior Financial Managers Forum
March 22, 2018
1931_1017
Home Health
Today’s Presenter
Lauri Domingo, RN
Home Health Clinical Consultant, J6 and JK
Provider Outreach and Education
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Disclaimer
National Government Services, Inc. has produced this material as an
informational reference for providers furnishing services in our contract
jurisdiction. National Government Services employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of
Medicare information is error-free and will bear no responsibility or
liability for the results or consequences of the use of this material.
Although every reasonable effort has been made to assure the accuracy
of the information within these pages at the time of publication, the
Medicare Program is constantly changing, and it is the responsibility of
each provider to remain abreast of the Medicare Program requirements.
Any regulations, policies and/or guidelines cited in this publication are
subject to change without further notice. Current Medicare regulations
can be found on the CMS website at https://www.cms.gov.
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No Recording
Attendees/providers are never permitted to record (tape record or
any other method) our educational events
This applies to our webinars, teleconferences, live events and any other type of
National Government Services educational events
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Objectives
Provide information and education on the Targeted Probe and
Educate Medical Review implemented October 1, 2017.
Share top reasons for denials and ways to avoid them.
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Agenda
Objectives of Medical Review
Targeted Probe & Educate (TPE) History
Changes in medical review process
Phases of TPE
Top Denials
CERT Error Rate
NYS Utilization Data
NGS Education
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Objective for Medical Review Activities
Objectives of any medical review is to:
Identify and prevent inappropriate payment
Identify potential risk to the Medicare trust fund
Educate providers
Appropriately pay for covered services
Medical review meets these objectives through medical review
activities
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Medical Review Process Change
The medical review process moved from a Progressive Corrective Action (PCA) process to a Targeted Probe and Educate (TPE)
Effective date of change was October 1, 2017
All lines of business
TPE
History
• Demonstration projects for inpatient services and home health
• Proved successful in lowering providers payment error rates
• New model changed some of the process but not affect policy and procedures
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Moving from a Demonstration Project to TPE
Differences between the demonstration projects for HH and inpatient services and the TPE MACs will select the area of review based on existing data analysis procedures
• CMS selected the area of review during the demonstration projects (HHTPE)
MACs can target the providers based on data rather than perform a 100% review of all providers
• All providers were subject to review during the demonstration project
MACs can perform post-pay or prepay reviews
MACs will provide education between each round of review
Education also occurring during the review process
20-40 claims for probes and each additional round of review
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Changes in the Medical Review Process – PCA vs TPE
Process for selecting and conducting medical review has changed
Specific number of claims to be reviewed during each round
• PCA allowed advancement of review activity based on percentages of all claims submitted
• PCA reviews and ADR requests quarterly
1:1 Education between each round
• Providers will have 45-56 days after the education before the next round of records will be requested
Intra-probe education – unique to TPE
• If the reviewer identifies something that can easily be corrected during the review phase, they will reach out to provider prior to rendering decision
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How Will Review Areas Be Selected?
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TPE Process
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ROUND 2 ROUND 3
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Initial Probe
During the initial probe providers can expect:
Provider Notification Letter
– Expect ADRs for TPE
– Reason for review
– Specific number noted in letter, between 20-40 claims
ADRs will be generated via the usual process
• Medical review within 30 days of receipt
• Provider results letter will offer 1:1 education
– Follow directions provided in the letter to request education
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Rounds of Review
TPE consists of three rounds if the provider continues to have a high payment error rate above 15% Initial probe
Round 2
Round 3
Education will occur prior to the 2nd and 3rd round of review 1:1 education with medical review after each round of review
Heavy emphasis on “Intra-round education” if the reviewer identifies missing documentation, sometimes several phone calls to provider (not an appeals means to be used later if provider disagrees, opportunity to send missing info during review)
ADR approximately 45-56 days after the education is complete
Detailed results letter
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CMS Referral
After three rounds of review and continued Payment Error Rate
above 15%, possibilities include:
Referral to the Zone Program Integrity Contractor or Unified Program Integrity
Contractor
Referral to the Recovery Audit Contractor
Extrapolation of payments based on
100% prepay review
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Validation Phase
Medical review of records for:
Physician orders
Medicare coverage guidelines
Documentation to support eligibility
Medical necessity of services
Physician certification of beneficiary eligibility
Documentation supports the services billed
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Calculations
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Calculations
Payment Error Rate (PER) - Dollars that are at risk to the Medicare trust fund. The payment
error rate will determine if a provider is released from medical review.
The PER is calculated by taking the dollars that Medicare would have paid you vs the dollars
medical review denied to obtain a percentage. For example if Medicare would have paid you a
thousand dollars and Medical review denied 500 dollars, your payment error rate would be
50% (example in previous slide). The PER is reported on your detailed provider specific
results letter.
A Claims Error Rate looks at the number of claims reviewed by the number of claims that were
denied. This was the calculation used in the HH Probe & Educate. For example if medical
review looks at 10 claims and denied 5 claims you have a 50% claims error rate.
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Detailed Provider Results Letter
Detailed results letter at the conclusion of each round will include:
Outline again the Targeted Probe & Educate process
Reason for denials including reference to the CMS regulations
Denial rates (PER)
Release or retention from medical review
• PER of 15% or below in order to be released from additional rounds of review
1:1 education information
Read the letter in its entirety for important information regarding additional rounds of review
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Top Denials - Medical Review and AppealsOctober 2017 – February 2018
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Top Denials Medical Review
• 55H4D = The medical documentation submitted did not show that the therapy
services were reasonable and necessary and at a level of complexity which
requires the skills of a therapist.
• 56900= The requested medical records were not received with the 45 day time
limit.
• 55HTW = The physician certification was invalid since the required face-to-face
encounter was missing/incomplete/untimely.
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Avoiding Denials for 55H4DDenial Code 55H4D – The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.
For any home health services to be covered by Medicare, the patient must meet the qualifying criteria as specified in §30, including having a need for skilled nursing care on an intermittent basis, physical therapy, speech-language pathology services, or a continuing need for occupational therapy as defined in this section.
Available Education: • Job Aid - Documentation to Support the Initial and Continued Need for Skilled Home Health Services, Billing G-Codes for
Therapy and Skilled Nursing Services
• Webinars – Home Health Eligibility: Clinical Documentation Requirements
• Medicare University CBT - Home Health Homebound Status & the Need for Skilled Services
• ADR Language includes therapy evaluations and reassessments
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Avoiding Denials for 56900Denial Code 56900– The requested medical records were not received with the 45 day time limit.
During the review process, if the provider fails to respond to a Medicare contractor’s Additional Documentation Request (ADR) within the prescribed time frame, the Medicare contractor shall deny the claim. See Pub. 100-08, Medicare Program Integrity Manual, chapter 3, section 3.4.1.2 for information on denials based on non-response to ADRs and section 3.4.1.4 for handling of late documentation.
Available Education:
• Job Aids – HH ADR Mock Chart Check List Suggestions
• Webinars – HH Documentation and the Additional Development Request
• Medicare University CBT - HH Documentation and the Additional Development Request
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Avoiding Denials for 55HTWDenial Code 55HTW - Face to Face Encounters -The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. Ensure there is documentation (a physician or allowed NPP clinical note) in the medical record that demonstrates that a face-to-face encounter has occurred within the required timeframe.
For episodes with starts of care beginning January 1, 2011 and later, in accordance with §30.5.1.1 below, a face-to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type. The certifying physician must also document the date of the encounter.
Available Education: • Job Aids - Face-to-Face Encounters 2016, HH Mock Chart Checklist Suggestions
• Webinars – HH Face-to-Face Encounter and the Plan of Care, Home Health Eligibility: Clinical Documentation Requirements
• Medicare University CBT - Face-to-face Encounters and the Plan of Care
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Appeals – Top Denials
• 37253 = The claim receipt date is more than 40 days after the OASIS assessment
completion date returned from QIES.
• 55H2B = Documentation submitted does not support homebound status
• 55HTW = The physician certification was invalid since the required face-to-face
encounter was missing/incomplete/untimely.
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Avoiding Denials for 37253Denial Code: 37253 The claim receipt date is more than 40 days after the OASIS assessment completion date returned from QIES.
OASIS reporting regulations require the OASIS to be transmitted within 30 days of completion (+10 days during transitional time). Before submitting an HH claim to your MAC, the HHA should ensure the OASIS assessment has completed processing and was successfully accepted into the QIES National Database. For the claim to be denied, the assessment must be both missing AND past due.
Available Education:
• Job Aids –OASIS Requirements, Billing the HH Final Episode Claim, Coding HH Episodes that span October 1, 2015,
• Webinars – HH Certification and Recertification, Home Health Billing Basics
• MLN Matters Number SE17009 released 3/24/17 - “Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information”
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Avoiding Denials for 55H2B
Denial Code: 55H2B – Homebound Status
• The Homebound status is not justified by the documentation in the certifying physician’s and/or the acute/post-acute care facility records. Examples of documentation to support homebound status may include: facility therapy notes, social work or discharge planning records, history and physicals, and other clinical progress notes.
Available Education: • Job Aids –Homebound Status, HH Mock Chart Checklist Suggestions
• Webinars – HH Homebound Status & the Need for Skilled Services, Home Health Eligibility: Clinical Documentation Requirements
• Medicare University CBT - Homebound Status & the Need for Skilled Services
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Avoiding Denials for 55HTWDenial Code 55HTW - Face to Face Encounters -The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. Ensure there is documentation (a physician or allowed NPP clinical note) in the medical record that demonstrates that a face-to-face encounter has occurred within the required timeframe.
For episodes with starts of care beginning January 1, 2011 and later, in accordance with §30.5.1.1 below, a face-to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type. The certifying physician must also document the date of the encounter.
Available Education: • Job Aids - Face-to-Face Encounters 2016, HH Mock Chart Checklist Suggestions
• Webinars – HH Face-to-Face Encounter and the Plan of Care, Home Health Eligibility: Clinical Documentation Requirements
• Medicare University CBT - Face-to-face Encounters and the Plan of Care
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Comprehensive Error Rate Testing Program (CERT)
= Improper Payment Rate
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What is an Improper Payment?
The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, CERT evaluates a statistically valid stratified random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.
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What is an Improper Payment?
The improper payment rate is a measure of compliance with and adherence to federal rules and requirements.
Under current Office of Management and Budget guidance, instances where there is insufficient or no documentation to support the payment as proper are cited as improper payments.
Improper payments are not always indicative of fraud nor do they necessarily represent expenses that should not have occurred.
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Improper Payments
The majority of Medicare FFS improper payments are due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary. In other words, when payments lack the appropriate supporting documentation, the payments’ validity cannot be determined. These are payments where more documentation is needed to determine if the claims were payable.
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Improper Payments
To reduce improper payments within the Medicare FFS program, CMS has developed a number of prevention and detective measures. CMS is taking a widespread approach that includes policy clarifications and simplifications, when appropriate, as well as Targeted Probe and Educate reviews, which include more individualized provider education through smaller probe reviews followed by specific education based on the findings of these reviews.
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Medicare FFS Jurisdiction Error Rate Contribution Score
An Error Rate Contribution Score was assigned to each jurisdiction
to reflect two key variables, the jurisdiction’s:
•Improper payment rate and
•Share of national improper payments
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2017 Home Health/ Hospice MAC Jurisdictions(Report Period July 1, 2015 – June 30, 2016)
Improper Payment Rate % of Total 2017 FFS Improper Pymts/ % of Total 2017 Medicare FFS Expenditures
Error Rate Contribution Score Label
J6 16.4% 4.4% - Low (0-8) 2.6% (NGS)
JK 10.8% 0.5% - Low (0-8) 0.4% (NGS)
JM 30.6% 15.0% - High (16-25) 4.7% (Palmetto SE and MW)
J15 20.8% 3.2% - Low (0-8) 1.5% (CGS center of country)
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-
FFS-Compliance-Programs/CERT/MedicareFFSJurisdictionErrorRateContributionData.html
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2017 Home Health/ Hospice MAC Jurisdictions(Report Period July 1, 2015 – June 30, 2016)
Comparison 2015/2016/2017
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NGS HHPPS Utilization Data for New York State
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10.1%
9%
5%
4%5%
10.5%
9%
5%5%
4%
9%
7.1%
3.8%
6%
5%
9%
6.5%
3.5%
7%
6%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Z47 Z48 L89 E11 J44
% D
iag
Ben
efic
iari
es
Diagnosis Codes
Trend in Top Five Diagnosis Codes (for Paid Dates Jul'17 - Dec'17) in New York
New York JanJun17
New York JulDec17
NGS HHA JulDec17
National JulDec17
State Diag Diag DescriptionNew York
JanJun17
New York
JulDec17
NGS HHA
JulDec17
National
JulDec17
33 NY Z47 Orthopedic Aftercare 10.1% 10.5% 9% 9%
33 NY Z48Encounter for other
postprocedural aftercare9% 9% 7.1% 6.5%
33 NY L89 Pressure Ulcer 5% 5% 3.8% 3.5%
33 NY E11 Diabetes Mellitus Type 2 4% 5% 6% 7%
33 NY J44Chronic Obstructive
Pulmonary Disease5% 4% 5% 6%
Home Health
Educational Opportunities
Ongoing Free Webinars:
Targeted Probe and Educate Webinar for the HH Audience
Home Health Eligibility: Clinical Documentation Requirements
HH Documentation & the Additional Development Request (ADR)
HH Certification & Recertification
NGS YouTube Channel
Targeted Probe and Educate (TPE) Medical Review Strategy
• https://www.youtube.com/watch?v=LqCaSummnNo
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Educational Opportunities –Annual NGS Medicare Summit 9/19-9/20 Las Vegas
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The Orleans Hotel and Casino
400 W. Tropicana Ave. Las Vegas, Nevada 89103 (702-365-7111) Use Summit Code A8MSC09 for special rate
Day 1: A general session for all HHH providers on disaster preparedness and
maintaining and developing a disaster preparedness plan to meet CMS requirements.
Day 2: Individual break-out sessions to address specific HHH billing and clinical
documentation.
Cost: $149 per person
Home Health
Educational Opportunities - Medicare University
Interactive online system available 24/7
Educational opportunities available
Computer-based training courses
Teleconferences, webinars, live seminars/face-to-face training
Self-report attendance
Website
http://www.MedicareUniversity.com
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Resources – Home Health Regulations
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf
CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c06.pdf
Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services”
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9119.pdf
In accordance with its references to Transmittal 92 & 208 in the CMS IOM Publications 100-01 and 100-02
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CMS Resources - TPE
CMS website
Change Request 10249, Transmittal 1919 “Targeted Probe and Educate”,
effective 10/1/2017
CMS TPE Flow Chart
Home Health Medical Review
Reducing Provider Burden
Targeted Probe and Educate (TPE)
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NGS Resources - TPE
NGS website: https://www.NGSMedicare.com
Choose contract, then Medical Policy & Review tab > Medical Review >
Targeted Probe and Educate
Choose contract, then News and Alerts > Home Health Medical Review and
CMS Suggested Documentation Tools
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Email Updates Subscribe to receive the latest Medicare information.
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Website and Portal Satisfaction –We Value Your Feedback
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