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Medical Reviews: Results and Risks

Recent postings from Medicare Administrative Contractors (MAC) Palmetto GBA and CGS Administrators have shown that the top reasons for claim denial are unchanged leading into 2022.




The undisputed “champion” of denials continues to be simply non-response to the Additional Development Requests (ADRs). This hovers around 46% for Palmetto GBA and 32% for CGA Administrators Targeted Probe and Educate (TPE) reviews. Quite simply: home health agencies are not even bothering to respond to the request: a sure way to generate a denial.


The second highest denial reason—and the top “actual” reason when looking at ADRs that were returned is face-to-face encounter requirements not met (Palmetto GBA 30%) or invalid/missing/untimely (CGS Administrators 17%). Face-to-face encounter issues have been topping the denial reasons since 2011 when it was first required.


Since certification issues get first look under medical review, the high percentage of denials issued on this basis covers up medical necessity issues. This is because if a claim does not meet technical requirements (e.g., face-to-face encounter, physician certification, OASIS submission) then the denial is issued and the review does not have to check for medical necessity.


In the broader picture, agencies need to keep in mind that despite the fact the Centers for Medicare and Medicaid Services (CMS) Public Health Emergency has no end in sight that the full scope of medical reviews has been restarted.


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.

Since most of these are targeted reviews based on claim and billing tendencies some lessons may be gleaned from looking at audits we have processed. Triggers for review and audits seem to be hitting on:

  • Claims with multiple recertifications.

  • Claims with a pattern of prior home health receipt: both the number of times on home health and any pattern of discharge/readmission.

  • Claims with visiting physician groups providing certification and physician services.

  • Low utilization of services: especially once weekly nursing service (1w9).

  • Agencies with a high percentage of community referrals; especially tied to visiting physician services.

  • A high number of claims with similar diagnoses. (e.g. osteoarthritis, hypertension, or hypertensive coronary artery disease)

These have been especially noticeable in prompting post-payment UPIC audits. Note that even if in a Review Choice Demonstration (RCD) state (Illinois, Ohio, Texas, North Carolina, or Florida) that a provisionally affirmed pre-claim reviewed claim does not guarantee it will pass a UPIC audit.


UPIC audits are especially difficult for agencies to deal with due to the high volume of records requested and the additional items requested beyond the medical record itself. Since most UPIC reviews start on a post-payment basis any subsequent denials result in an identified overpayment situation and a significant risk that the denied amount will be extrapolated to a much larger denial amount. Both of these are bad outcomes.


Too many home health agencies lack ongoing quality assurance reviews and depend on their Electronic Medical Record (EMR) system to generate valid billable documentation. And too many agencies then find out the hard way that what has been going into their records does not support payment when undergoing Medical Review scrutiny.


Clinicians need to know what to put into that EMR to keep the visit and claim compliant. Teaching on home safety, COVID infection control, and repeated instruction on the same topics over multiple visits generates denials.


What to do? Keep up to date on your agency’s MAC website for focus areas. Perform a real evaluation of your agency’s utilization practices. Assess your agency’s EMR for its ability to guide clinicians to generate payable visits. And—in case of review—get assistance to put your best foot forward and minimize the chance of denial.


If a review or audit result is unfavorable—get assistance with the response to get the right documents to the right place with the right content at the right time. And be prepared for a long-haul in the appeals process if you wish to recover any denied monies.


Know the risks to obtain better results.

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