Tuesday, September 12 | Post-Acute Care, Revenue Cycle/Billing
Additional documentation requests (ADR) are the norm today – everyone in home health gets them. Perhaps the best defense of documentation requests from payers (specifically Medicare) might be a stout offense that boasts an aggressive strategy of documenting every procedure at the point of care and providing specific details of the patient health plan. But even when taking an aggressive approach to defending services provided — with detailed documentation — of the patient experience, there still may be some instances when home health administrators must take action.
To do so, however, it may be worthwhile to understand exactly what some of the top reason for denial of payment are throughout the first quarter of 2017.
For CGS-processed claims, they list their top denials as: skilled nursing services were not medically necessary; physician’s certification was invalid since the required face-to-face (F2F) encounter was missing/incomplete/untimely; requested documentation was not received/or not received timely; documentation did not show that therapy services were reasonable or necessary; and initial certification was missing/incomplete/invalid, therefore, the re-certification episode is denied.
For PGBA-processed claims, they list their top denials as: requested records were not submitted; F2F encounter requirements were not met; Health Insurance Prospective Payment System (HIPPS) code change because of partial denial of therapy; no plan of care or certification; info provided does not support the medical necessity for therapy services; and unable to determine medical necessity of HIPPS code billed as appropriate, OASIS not submitted.
For NGS-processed claims, they list their top denials as: documentation submitted does not support homebound status; medical necessity not supported as OASIS not submitted; skilled observation was not needed from the start of care; skilled nursing services were not medically necessary; requested documentation not received/received untimely.
There are still many, many other reasons for denial of claims. Some of these include:
Home health administrators must review claims and must have a process in place to review end of episodes so they are clean for billing. This doesn’t mean you must quality assets (QA) 100 percent of the charts you process, but establish some sort of protocol that ensures members of your QA team review end of episodes before they are billed. In the case of responding to ADRs, they should be sent with a signed receipt request so you are able to track the documents so that you can see when the documents arrived at the claims processor and who signed for them.
Administrators also should ensure that education is provided to staff during orientation, and annually on the coverage guidelines for clinicians, so they understand what is expected to re-certify a patient for care.
Also, it’s important to understand that your caregivers should not be allowed to turn in late paperwork. Notes that are completed long after the visit are rarely accurate and these notes are reviewed in the event of an audit. Each visit note for all disciplines must stand alone and provide needed.
When it comes to documentation, the only way to go forward is transparently and the best way to do that is to be as educated as possible on best practices. Join us next time for part II of our blog series medical documentation where we’ll discuss specific areas of focus to ensure that your documentation is as thorough as possible to help ease the pain an audit can bring.
Entire blog post originally posted on DeVero, a Netsmart Solution’s blog onJuly 31, 2017.
Wednesday, January 25 | Thought Leadership,Post-Acute Care,Value-based Care
From workforce issues to value-based reimbursement models and legislative & regulatory change, there is plenty for hospice and home care agencies to keep an eye on in 2023. The National Association of Home Care & Hospice (NAHC) President Bill Dombi discusses the trends of the new year and offers his expert advice on how to navigate the coming months.More
Tuesday, December 20 | Thought Leadership,Post-Acute Care,Value-based Care
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Thursday, December 01 | Thought Leadership,Post-Acute Care,Value-based Care
Most payers believe a majority of their contracts will be value-based within a few years. Some of them are already preparing while others haven't made the change. We take a look at five steps to help with the transition to a value-based payment model.More