Home Health Targeted Probe and Educate

As many agencies are aware and undergoing, CMS has implemented a Targeted Probe and Educate program.  Aside from the obvious jokes about being probed by Medicare and feeling uncomfortable, the probes are serious.

Round 2 of the probe and educate will soon be underway for many agencies.  Home health agencies aren’t the only group of providers targeted either.  Across the healthcare continuum, almost every provider group is undergoing the same request for between 20 and 40 records.

Agencies need to really make sure they do their best to get everything right on the second round.  CMS isn’t pulling any punches when it issues a third round of probes.  Agencies must also participate in the education portion of the demonstration.  We keep hearing that agencies are trying to appeal the decisions but are not participating in the education.

The lack of participation in finding out why claims and charts are rejected is important. Not only will you receive some additional rational for how your intermediary reviews the documentation, it will also allow for questions and follow up.  On top of your own education, CMS has determined that agencies who do not partake in the educational portion will have another black mark against their agency which could result in more probe and educate requests.

Besides recouping reimbursement from your agency, probe and educate has a much larger effect on future payments.  If your agency does not successfully pass after the third round of probes, the consequences could be severe, up to possible criminal referral for fraud.

The likely situations to occur for failing to pass the third round include varied sanctions and actions.

  1. Prepayment Review: You must submit all claims and documentation to the intermediary for payment. Electronic claims and automatic processing of RAPs and Finals/EOEs is suspended.  An intermediary employee (we use that term as there seems to be few qualified staff at any intermediary) must review the entire chart to ensure compliance with regulations. Should you fail to meet any of the requirements, the chart will be rejected and need to be resubmitted with the correct documentation. Be aware that many times charts are complete and compliant, but the lackluster employee at the intermediary can miss quite a bit even you’re your highlighting, big bold letters, and clear flagging. These people seriously make Mr. Magoo seem like he has 20/20 vision.
  2. Extrapolation: It’s a real term and a real possibility. Your intermediary can use a sample size to determine an error rate and go back to 6 years of reimbursement to seek recoupments.  Can you imagine going back 6 years because some cog in the bureaucratic wheel was too lazy, or too incompetent, or just having a bad day and missed large chunks of requested documentation taking your agency right out from under you?
  3. RAC Audit: The RAC[et] is back and coming for those who don’t comply. With the power similar to that of an intermediary, a RAC auditor can use the same method to take a sample of claims, assign an error rate, and bankrupt your agency. A RAC auditor doesn’t get paid unless they find something of value, so they always find something without regard to legitimacy.
  4. ZPICs and a new one UPICs: Cloaked under “fraud and abuse” these lovely audit programs are especially looking for anything that could qualify under the loosely, ever changing definitions. Just like a RAC auditor, these auditors only get paid when they find that someone screwed up or just possibly screwed up. They don’t care if they missed something, their goal is to make money off your agency.
  5. Termination: Intermediaries and CMS have the ability to terminate your participation in the Medicare program as a provider. Look out for this to be frequently challenged in court, should they start doing this to freestanding providers while allowing publicly traded companies to get away with slaps on the wrist.  Just wait for it – we’ve seen it before. Publicly traded companies get a quick fine and then fall right back into the good graces of CMS.
  6. OIG and DOJ: Should the intermediary think your agency is really doing something wrong, they will just issue your death warrant. A referral to OIG and DOJ means that your agency will likely go under severe audit and review by multiple government agencies. Likely the OIG will start and then they will bring in the DOJ. This is a very rare circumstance, but it does happen.

What is an agency to do? Well first, make sure you have a strong QA program and make sure your QA person really has a good grasp of what’s going on.  While it’s nice to have a QA person and program stuck in a binder on the bookshelf, make sure it works.  Dust off the policy and procedure manual, update it not only for the COPs, but also take a good hard look at your QA program.

QA is not only going to save your agency from the brink of disaster but it also pays for itself with increased reimbursement. A good QA program generally catches issues before a chart is sent to the deep dark whole of medical records archives. QA also serves as a guide for educating staff who seem to need constant reminders.

If your agency is too small to have a full time QA person, we suggest you find a qualified, outsourced reviewer who can achieve this task for you. Should you need a recommendation, please contact us and we’d be more than happy to assist you.

More information will be coming out in the next couple of months on probe and educate. We will be providing information as it comes out so be sure to check out our blogs at www.tortolanoandco.com and www.optimabiling.com for up to date coverage and developments.

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