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Medical Review 2022: Everything Old is Renewed Again

With the end of 2021 and start of 2022 it is time to take a quick look at the world of Medical Review and what agencies may be seeing in the new year.


First up is that the Centers for Medicare and Medicaid Services (CMS) Public Health Emergency has continued to be renewed and currently has no end in sight.


The Secretary of the HHS declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020, HHS authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020. CMS PHE


Initially some Medicare contractor medical reviews were paused, but going into 2022 the full scope and force of medical reviews are back on the table. This means that home health agencies may receive Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Comprehensive Error Rate Testing (CERT) reviews.


TPE activity has already been seen in multiple areas across the country. In addition, the Review Choice Demonstration (RCD) has reached the half-way point of its five-year duration but is in full effect in Illinois, Ohio, Texas, North Carolina, and Florida.


As if that was not enough, Medicare Advantage reviews continued during the CMS review pause and have seemingly picked up as well. This is driven in part by the rapid growth of beneficiaries under Medicare Advantage plans.


The no-pay Request for Anticipated Payment (RAP) is history with the simpler Notice of Admission (NOA) applicable to billing periods starting in 2022. The need to get this correct and submitted timely may have significant financial ramifications as its learning curve is flattened and this new requirement is implemented.


For compliance issues, eleven years after its implementation the top denial reason for home health claims (once they have been submitted for review—nearly HALF of Additional Development Requests are not even returned!) remains physician face-to-face (F2F) encounter issues. Ongoing efforts to improve compliance with F2F is the “new” being the same as the “old.”


The ability of allowed (non-physician) practitioners to certify and order home health plans of care is perhaps the biggest change in coverage issues. However, this is still limited by state specific requirements. Telehealth service remains non-billable and unusable to satisfy visit requirements related to Low Utilization Payment Adjustments (LUPA).


Claims posing higher risk for reviews remain those with multiple recertifications, similar referral sources and ordering physicians, and certain diagnoses that have historically been cited for their general nature. Medicare Advantage audits continue to follow long length of service patients, certain diagnoses, and claims with therapy usage (focused on content of the required 30-day reassessments).


One piece of good news is that the huge wait time for Administrative Law Judge (ALJ) hearings has shown a rapid and significant decline. The opening of new Office of Medicare Hearings and Appeals (OMHA) offices and hiring of many new ALJs has resulted in a noticeable decline in the filing-to-hearing wait time, although still not to the 90-day statutory requirement. Keep in mind that when you get your day in court that the judge may not be as versed on home health coverage requirements as you will be; so clearly explaining how the service provided complied with applicable specific regulations will do you in good stead.

So as 2022 dawns it looks like things are slowly returning to the level of pre-PHE medical review activity. Agencies must continue to deal with the complications of Covid while managing PHE allowed clinical waivers (such as telehealth). So in 2022, getting the NOA in order, setting up a strong F2F compliance system, and keeping visit staff up to date on what needs to be in their charting are the continued keys to success.


Happy New Year!

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