CMS Issues Instructions for the Home Health Probe and Educate Review
November 11, 2015 09:47 AM
The Centers for Medicare & Medicaid Services (CMS) has issued MLN Matters® article SE1524 which provides instructions on the Probe and Educate Review strategy for home health agencies (HHAs).
Earlier this year, CMS announced its plans to begin a Probe and Educate strategy for reviewing claims submitted by HHAs related to Medicare home health services and patient eligibility (certification/re-certification) as outlined in the 2015 final rule for the home health prospective payment system. However, agencies have been waiting for CMS to officially announce the specifics regarding implementing the Probe and Educate plan.
CMS anticipates the Medicare Administrative Contractors (MACs) will begin sending Additional Documentation Requests (ADRs) after October 1, 2015, and that the first round of claim reviews and provider education will conclude in approximately one year.
CMS will direct the MACs to select a sample of 5 claims for pre-payment review from each HHA within their jurisdiction.
Based on the results of these initial reviews, the MACs will conduct provider specific educational outreach. The MACs will deny each non-compliant claim and outline the reasons for denial in a letter to the HHA, which will be sent at the conclusion of the probe review. CMS also instructs the MACs to offer individualized telephone calls/education to all providers with errors in their claim sample. During such calls, the MAC will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.
In addition to these educational outreach efforts, for those providers that are identified as having moderate or major concerns, the MACs will repeat the Probe and Educate process for dates of services occurring after education has been provided. The MLN matters® article includes a table that outlines the actions the MAC will follow depending on results of the Probe and Educate review.