Probe and Educate Strategy Continues

CMS Announces a Continuation of the Home Health Probe and Educate Medical Review Strategy

In the December 16, 2016 MLN Release (SE1635), CMS announced that Medicare Administrative Contractors (MACs), in conjunction with CMS, have initiated Round 2 of the Probe and Educate Strategy for home health providers. This will be effective on or after December 15, 2016. The original Probe and Educate Strategy was constructed following a significant change in the CY 2015 Home Health PPS Final Rule. For providers, the specific change surrounding the F2F included the removal of the narrative requirement for the certification of the patient for home health. The final rule included the new expectations for how the certifying physician, or NPP, could incorporate the reasons for home health into the accompanying medical record from either the physician or the facility. Lastly, it outlined allowances for the physician to use portions from the home health medical record in the certification.

The first round of the probe involved select agencies experiencing five additional document requests (ADRs). The feedback from the ADRs offered details on agency deficiencies, along with an offer to provide additional education. With this second round, the anticipated strategy conclusion is one year from the date it is initiated. CMS is directing home heath MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction, excluding those providers who had five claims reviewed in Round 1, with zero or one claim in error.

Whether or not your agency is included in this probe, QIRT has the solution to relieve ADR anxiety. Our expanded internal audit team is well versed in pre-claim audits. Let our team partner with your agency to provide a full audit of your claim-related data. Audits are conducted using the compliance measures CMS expects to be used when reviewing for medical necessity and full face-to-face compliance. Our team will audit the record and then partner with your team to educate on specific deficiencies. The QIRT compliance team can also prepare your already selected ADRs and submit to your MAC on your behalf. Call QIRT today for a discussion on how we can help!

Stefanie Woodrow


2 thoughts on “Probe and Educate Strategy Continues

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  1. How does overturned denials fit into the equation? For example, if an agency received two or more denials in the first P & E round, but all denials were overturned on appeal, is the agency still standing before CMS’ firing squad for P & E round two?

    1. Yes. While a denial/error rate is supposed to be recalculated based on some appeal results and disposition, in general the review result itself (i.e., if the ADR is paid or not) determines what future action will be taken for future review.

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