Home Health Medical Review is experiencing another surge, although not as significant as the escalation observed in hospice. Nevertheless, it’s proving to be a challenge for several home health agencies.

Understanding the type of review you’re facing and being prepared to respond effectively is crucial. Targeted Probe and Educate audits are currently the primary audits encountered by home health agencies through Medicare MACs. These audits typically involve a letter from Medicare MACs, indicating an audit of 20 to 40 claims. Denial percentages are calculated after each review level, and surpassing the acceptable denial percentage prompts progression to the next round.

A crucial aspect of advancing to the next round is knowing that after your education call with Medicare MAC, there’s a 45-day waiting period before the next level of review starts. This offers you the opportunity to make adjustments and edits to your charting to avoid denials for the same reasons as in the previous round.

Other levels of medical review comprise UPIC audits, SMRC audits, and CERT audits that effects most agencies at least bi-annually, typically focusing on only one or two charts—and RAC audits (Recovery Audit Contractor) audits, which have regained prominence in home health and hospice since the conclusion of the Public Health Emergency. The recovery audits are overseen by a single audit company, Performant, and typically involve the examination of one or two charts at a time. It’s crucial to respond to them in the same manner as any other audit. Moreover, there has been an increase in OIG audits where charts are directly forwarded to the OIG for medical review and response. Appeals are directed back to the OIG for evaluation instead of following the standard appeals process.

No matter the review level you’re facing, it’s crucial to be fully cooperative and respond promptly. Timely appeals for any denials are especially important. In cases of UPIC or SMRC audits, there’s a possibility of extrapolation, where your denial percentage is projected over the entire audit period. For instance, $200,000 could potentially escalate to $2,000,000 with volume applied. Filing appeals promptly can halt the recoupment process until the appeals are resolved.

The Administrative Law Judge (ALJ) represents the highest level of review for appeals that home health agencies can pursue. We strongly advocate for persistence and advise against giving up. For instance, some believe that a signed order without a dated signature is an insurmountable obstacle, but that’s not always true. Appeals have been overturned in cases when the physician provided an attestation regarding the date of their original signature. While it’s not always successful, it has happened. However, caution should be used against pursuing appeals for issues that cannot be rectified, such as orders that have not been signed at all.

It’s important to note that whenever you receive a subjective denial, like insufficient documentation for medical necessity, you have the chance to request that clinicians or physicians provide attestations along with any additional documentation you may have left out, including testing or laboratory results that could strengthen your case for medical necessity. It’s essential to exhaust all options and not lose hope. Several ALJ hearings have been won simply by presenting highly detailed, specific information that prompted them to overturn the denial decision.

It’s crucial to promptly address any audits you receive, engage with the reviewers, and ensure they recognize your full cooperation. This level of attentiveness is extremely important.

When compiling charts, it’s essential to have them clinically reviewed to ensure all necessary clinical information is included. This involves appropriately including a table of contents, paginating the document, and adding a cover letter to guide the reviewer through the chart.

Should you need assistance, Healthcare Provider Solutions is here to help in any way during medical reviews. Please feel free to reach out to us.

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