5 top reasons for claim denials

Targeted Probe and Educate (TPE) results from Palmetto show where home health agencies are struggling

With the Review Choice demonstration looming for home care providers in Ohio, Florida, Texas and North Carolina, new statistics from Medicare administrative contractor Palmetto GBA are highlighting five areas in which home health agencies struggle to get it right.

Palmetto has posted to its web site Targeted Probe and Educate (TPE) results showing the top five reasons for claim denials between Oct. 1, 2017, and July 24, 2019.

The list shows inadequate face-to-face documentation and problems with showing the need for skilled services continue to plague home health agencies. Additional reasons for home health denials were problems with the plan of care or certification, missing physician orders, and failure to document services provided.

"These are areas agencies are going to need to work on prior to joining the Review Choice demonstration," said J'non Griffin, owner and president of Home Health Solutions. "In some ways, this is a line item list of exactly what needs to be cleaned up."

After Ohio, who?

Ohio providers are making their Review Choice selections now as they prepare to join home health agencies in Illinois in the Review Choice demonstration at the end of September. Meanwhile providers in Florida, Texas and North Carolina are still waiting on word from the Centers for Medicare and Medicaid Services (CMS) about when they'll join.

And there is some industry buzz about what TPE results may tell us regarding which state will go next, according to J'non. In Texas, where 642 of 1,174 providers who underwent the first round of TPE are now progressing to the Probe 2, and 19 are moving on to Probe 3, intensive preparation and training efforts are underway at this week's 50th annual Texas Home Care Association meeting. Texas had the highest TPE numbers reported by Palmetto. In Florida, 37 providers will progress to Probe 2, and in North Carolina, 17 will progress to Probe 2. A handful of North Carolina providers have already moved on to Probe 3.

Each probe is designed to identify where providers are found to be non-compliant and at risk of denial. Providers must achieve a minimum compliance rate to be exempt from the next highest probe level. Palmetto offers education and training to agencies found to be non-compliant during TPE probes.

We can help

Home Health Solutions offers products specifically designed to help agencies shore up their compliance rates in the five areas identified as top risks for claim denials. Our "Dirty Dozen" guide, available for just $24.99 in our online store, details the 12 common mistakes made by home care providers in their face-to-face documentation.

Our "Review Choice 101" guide, sold for $99, provides 101 tips for creating documentation designed to pass reviewer scrutiny. With chapters targeting medical necessity and the F2F, it zeroes in on areas in which agencies are most vulnerable as they head into Review Choice. Plus, the entire guide is provided in quick-to-read checklist form for busy professionals! Check out our helpful products here!