Federal home health regulations must be met to participate in Medicare and Medicaid programs. When providers become a Medicare-certified home health agency, they agree to focus on providing quality care and protecting the health and safety of the beneficiaries they serve. While the various subparts of the federal home health regulations serve different purposes, they all require compliant implementation and supported documentation, as there is scrutiny of both these items during a survey or an audit.

This blog updates and summarizes recent focus medical review from the Medicare Administrative Contractors (MACs – CGS, Palmetto, and Noridian) to better understand the action needed for proactive approaches versus responding to document requests reactively. Staying vigilant and updated on regulatory requirements creates a foundation of compliance and quality in your agency operations and ultimately, financial stability.

Let’s start with a summary of 2022 top denial reasons for the MACs.

  • CGS
    • Skilled nursing services not medically necessary
    • Initial certification missing/incomplete/invalid; therefore, the recertification episode was denied
    • Physician certification denied due to missing/incomplete/untimely Face-to-face encounter
    • The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity requiring a therapist’s skills
    • Physician or allowed practitioner’s plan of care and/or certification present -no signature
  • Palmetto
    • Face-to-face encounter requirements not met
    • Requested records not submitted
    • No plan of care or certification
    • Information provided does not support the medical necessity for this service
    • No physician’s orders for services
  • NGS
    • No response from medical record request
    • Certification missing/incomplete/invalid
    • Skilled nursing services not medically necessary
    • Requirements not met for daily care

Additional Development Requests (ADRs) are issued to review documentation for errors and inconsistencies in claims or when other documentation is needed to complete the claim. The overall goal is to identify overpayments and protect the Medicare Trust Fund.

Claims data trends are used to decide which provider receives ADRs. These reviews focus on various aspects of the claim, such as missing, incomplete or invalid Plan of Care signatures, documentation quality, the NPI and/or physician’s last name submitted on the home health claim does not match the physician’s information in PECOS, and more. It is also critical for home health providers to ensure that the diagnosis coding on the claim form is accurate.  Given the implementation of the Patient-Driven Groupings Model (PDGM) and the relationship of the primary diagnosis coding with the Face-to-Face Encounter, providers need to understand the coding aspect of documentation clearly and thoroughly.

Being proactive is the best action to prepare for an ADR, it reduces the risk of denials and saves money. Remember, being reactive is far more costly than being proactive.  A proactive stance also involves audit readiness by performing compliance and quality monitoring of processes, and reviewing billing compliance for continued data monitoring. One proactive step is completing a review of a clinical record before claim submission. It is best practice to perform pre-bill claim reviews by a clinical team member, including a review of all technical elements.

At a minimum, reviewing a sampling of records to identify potential risks will support a proactive approach. Monitor your PEPPER (Program for Evaluating Payment Patterns Electronic Report) reports and claims data analysis to identify trends. If your agency is not conducting clinical pre-billing reviews prior to claim submission, it is strongly recommended to add this to your next QAPI plan to help reduce risk and expense on reimbursement issues.

Be familiar with your MAC’s information and resources related to medical review. Knowing their process and targets for ADRs is half the battle.

Dawn B. Cheek, BSN, Director Clinical Consulting

Jennifer Kennedy, EdD, BAN, RN, CHC, VP, Quality, Standards, & Compliance


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