By Michelle Bedoya and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law.
Medicare Administrative Contractors (MACs) in conjunction with the Center for Medicare and Medicaid Services (CMS) have initialized the “Home Health Probe and Educate” medical review strategy. The reason for CMS’s coined “Probe and Educate Review Strategy” is to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements.
Pre-Payment Claim Review.
The strategy requires home health MACs to select a sample of five claims for pre-payment review from every home health agency within the MACs jurisdiction. Probe reviews shall assess claims submitted by home health agencies related to Medicare home health services and patient eligibility. Home health episodes that began on or after August 1, 2015, will be selected during the “Probe and Educate” program.
The Probe: Initial Review.
Reviews will appear to each home health provider in the form of Additional Development Requests (ADRs) on any date after October 15, 2015. It is anticipated that the first round of claims reviewed will conclude in approximately one year from October 15, 2015.
Providers must affirmatively look out for ADRs from their MACs. Since ADRs adhere to strict deadlines, providers should ensure that they allow ample time for mailing and processing of documentation. Doing so will prevent the claim from inadvertently being denied.
Upon initial review, CMS has instructed MACs to deny each non-compliant claim. If claims are denied, a letter outlining the reasons for denial will be sent to the home health agency at the conclusion of the review.
The Education: Post Review Results.
MACs will conduct provider specific educational outreach based on the results of the initial reviews. The outreach shall consist of an offer by MACs to provide individualized telephone calls/education to all providers who produced non-compliant claims. During the call, the MAC will:
1. discuss the reasons for denial;
2. provide education relevant to those reason;
3. provide reference materials; and
4. answer questions.
Further Review: Providers Having Moderate/Major Concerns.
As a result of the initial reviews, providers will be classified into two categories:
1. No or Minor Concerns; or
2. Moderate/Major Concerns.
For those providers that are categorized as having moderate or major concerns, MACs will repeat the “Probe and Educate Process” for dates of service occurring after the education was provided. CMS is silent as to action if improvement is not realized during the second review.
Conclusion.
CMS maintains it has no authority to pay claims where the criterion for Medicare coverage is not evident. Thus, it is vital that providers ensure that medical records are compliant and adhere to Medicare guidelines.
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Sources:
“Selecting Home Health Claims for Probe and Educate Review: Episodes that Begin on or After August 1, 2015”, MLN Matters SE1524. U.S. Department of Health and Human Services: Centers for Medicare & Medicaid Services, 2015.
About the Author: Michelle Bedoya is a long-time consultant to home health agencies and is currently a student at Barry University School of Law. George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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