CorporateBusiness Services

August 29, 2013

Widespread Home Health Probe – Utah Home Health Providers

The goal of CGS's medical review (MR) program is to reduce errors by preventing the initial payment of claims that do not comply with Medicare's coverage, coding, payment and billing policies. To achieve this goal, we conduct data analysis to identify provider billing practices and services that pose the greatest risk to the Medicare program.

Based on our most recent analysis of billing data, home health providers in the state of Utah have been shown to have greater aberrancies in comparison to the universe of CGS providers in average reimbursement per claim, average total visits, average total therapy visits, percent of claims with therapy services and percent of claims with 20+ therapy visits. In addition, an OIG report titled Inappropriate and Questionable Billing by Medicare Home Health Agencies identified the state of Utah as one of eight states that had high percentages of agencies with questionable billing practices.

As a result, CGS will be initiating a state specific widespread probe for all Utah home health providers. The topic code for this review will be 5012W, and the probe will select claims with 10 or more therapy visits. Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity, compliance with all CMS coverage guidelines, and correct billing and coding.

Provider Action Needed to Prepare for the Edit

HHAs should take action now to ensure that they have procedures and processes in place to appropriately identify and respond to claims that are selected for Medical Review by this edit, including:

  • Checking for claims in the Additional Development Request (ADR) status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
  • Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
  • Mailing your documentation for claims selected to CGS by day 30.

More information regarding Additional Development Request (ADR) process is available at http://www.cgsmedicare.com/hhh/medreview/adr_process.html


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