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Medical Review Responses: What to Do?


Nearly all home health and hospice agencies will at one time or another experience some form of Medicare Medical Review (MR) CMS Medical Review . This is a separate process than surveys and is focused on determining whether payment can be made (pre-payment review) or was correctly made (post payment review).


This is accomplished by a variety of contractors utilizing Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE), Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Comprehensive Error Rate Testing (CERT) reviews. Each presents a different challenge to the home health or hospice agency.


Briefly:


Medicare Administrative Contractor (MAC) Targeted Probe & Educate (TPE)

20-40 Additional Development/Document Requests (ADRs). Up to three rounds. Education provided between rounds. Often pre-payment review. Based on edits: comparison to similar agencies or geographic areas. Target a type or pattern of billing performed by the agency. Areas under review may be specified on each MAC website. TPE

Risk to Agency: Medium

Agency Response Effort: Medium


Unified Program Integrity Contractor (UPIC)

Unlimited number of ADRs, usually as one combined record request. Depending on results may require ongoing ADR submissions. Usually post payment review. Based on credible information of inappropriate, wasteful, or possibly fraudulent billing. Targeted based on agency geographical location, billing trends, hotline calls, changes in billing from a prior period, etc. May also include on-site visits from reviewers and visits to/interviews with current or prior patients. Since done post payment runs risk of generating an extrapolation of findings.

Risk to Agency: High

Agency Response Effort: High


Recovery Audit Contractor (RAC)

Usually single ADR at a time. Limited in the number of ADRs over time. Post payment review. Based on edits: comparison to similar agencies or geographic areas. Target a type of billing performed by the agency. RAC

Risk to Agency: Low

Agency Response Effort: Low


Supplemental Medical Review Contractor (SMRC)

Usually, multiple ADRs. Usually only one request for records. Post payment review. Based on edits: comparison to similar agencies or geographic areas. Targets a type of billing performed by the agency (e.g., home health therapy use; hospice General Inpatient level of care). Areas of review are specified by CMS. SMRC

Risk to Agency: Medium

Agency Response Effort: Medium


Comprehensive Error Rate Testing (CERT) reviews

Usually single ADR at a time. Post payment review. Targeted on a type of billing performed by the agency. Purpose is to determine accuracy of payments made. CERT

Risk to Agency: Low

Agency Response Effort: Low


Other reviews: Medicare Advantage, commercial insurance (e.g., Blue Cross, Humana, United Health Care, etc.)

Depends on the requesting entity for how may records, whether pre-payment or post payment, scope of review, length of review, what is targeted.

Risk to Agency: Medium

Agency Response Effort: Medium—may progress towards High


Agency responses

Based on the admittedly simplifications above, guidance on agency response to these reviews include:

  • Depending on agency resources, RAC, SMRC, and CERT reviews are generally able to be handled internally.

  • TPE may present a bigger challenge due to the need for gathering more content, generating the ADR and getting it submitted timely.

  • UPIC audits’ scope and nature of the review generally require outside assistance. This should be done in collaboration with the agency to ensure all requested documents, policies, and administrative items are submitted.

  • Obtaining health care attorney assistance is recommended for most UPIC audits since there is a significant risk for high actual denial amounts, extrapolation of those amounts into a much higher amount, and even possible payment suspension if the review results are not favorable.

  • Getting the ADR paid gives the best return on agency resources since a paid claim does not have to undergo any of the appeals process.

  • However, keep in mind that ALL ADRs and records requested have been final billed. This means that investing time and effort to review or “QA” the ADR does not provide an opportunity to correct most items. This especially relates to technical items such as certification, face-to-face encounters, signed orders, and visits billed matching visits made.

  • Note that summaries and late entries made after final billing do not have to be considered by medical reviewers since they were not part of the original clinical record. They MAY be considered at discretion of the reviewer but your record must “speak for itself” and support the billing for that claim.

  • All record amendments, corrections, and late entries must be in accordance with the Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.3.2.5 PIM that states: “All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations the MACs, CERT, Recovery Auditors, SMRC and UPICs shall consider all submitted entries that comply with the widely accepted Record keeping Principles…The MACs, CERT, Recovery Auditors, SMRC and UPICs shall NOT consider any entries that do not comply with the principles listed…even if such exclusion would lead to a claim denial.”

  • For any type of review, if agency staff are not familiar with the process, possible issues, and risks, it may be beneficial to reach out for consultant assistance and guidance.

  • Getting the correct information to the requestor is very important since the ADR content will form the basis of any case file developed in the appeals process.


Agencies need to be aware that they are always subject to medical reviews—even those in Review Choice Demonstration (RCD) states. Basically, all of MR is targeted. This puts the onus on the agency to provide and document compliant charts at the time of service and prior to final billing.


Once involved in the MR process, assess your agency knowledge level, comfort level, and resources to minimize unfavorable outcomes. It’s better (and sometimes easier) to get the record response in order so that you are submitting your records in an organized, most favorable light so that you do not have to try the appeals process.


Since Medical Review is not a common part of agency operations, if unsure what you are facing it is beneficial to seek assistance and guidance from outside resources. The ramifications of an unfavorable review far outweigh the costs incurred in generating an organized positive response to the record request.

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