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News and Press: Medicare

Palmetto GBA Announces Expansion of the "Probe and Educate" Initiative

Friday, July 7, 2017   (0 Comments)

The Palmetto GBA 16 State Coalition, of which HCAF is a member, is now hearing from Palmetto GBA that they have expanded their Probe and Educate initiative in a very significant way. Agencies that “fail” the second round (meaning two or more of the five records reviewed denied) are being placed under a provider-specific review. This review will be extensive with 20-40 records on average being requested, not just another five records like in previous rounds.

If your agency is forced into this specific review, please notify HCAF by emailing Bobby Lolley and/or Kyle Simon directly. As your advocate, HCAF staff needs to understand how many providers in Florida are being affected by this new initiative. Understanding the scope of the problem is critical in our efforts to advocate for either more effective education or the elimination of the face-to-face encounter requirement all together.

You may see this code in DDE:

 

52CF1-THIS HOME HEALTH CLAIM WAS SELECTED FOR PREPAYMENT PROVIDER SPECIFIC PROBE REVIEW FOR VALIDATION OF CMS-1611-F, CALENDAR YEAR (CY) 2015 HOME HEALTH PROPSPECTIVE PAYMENT SYSTME (HH PPS) FINAL RULE. ADDITIONAL DOCUMENTATION REQUESTS THAT RESULT IN DENIALS FOR NON-RESPONSE DURING ANY ROUND OF PROBE AND EDUCATE (P&E) OR CONTINUED HIGH DENIAL RATES AFTER MULTIPLE ROUNDS OF P&E WILL RESULT IN A RAC REFERRAL.


All agencies in Round 2 can be subject to further review even those agencies that did not complete Round 1 before that round was suspended.

The coalition jointly asked Palmetto GBA about whether agencies can be moved to the next round before they have an opportunity for education in Round 2. Here is their response:

 Providers are being progressed if they did not request education on or before their due date. We have a number of providers that missed their deadline to request education, so yes, there is a chance that they have been progressed before they are receiving their education.  

 

 Again this provider-specific review will request 20-40 records.

Just a reminder that claims may suspend in a different status location. Only those in S B6001 will generate an ADR. See below.

 

 Claim Selection Process for the Home Health Probe and Educate Medical Review

 

 When a claim is selected for possible Probe and Educate review, it will go into an S B6000 location in Direct Data Entry (DDE). When the claim goes to this location there will be narrative that indicates the claim was selected and documentation is requested. However, you should not respond with medical documentation until the claim moves to S B6001 location. When a claim goes into S B6001 location, it generates an ADR and it will hold in that location until the records are received.

 

For the Home Health Probe and Educate edit, more than five claims may be initially pulled into the S B6000 location to ensure the review criteria are met. Only claims that are selected for review will move from S B6000 to S B6001. Do not send in medical documentation unless the claim suspends to location S B6001, when the ADR will be generated.


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