Probe and Educate Review for F2F, Medicare Eligibility

The Centers for Medicare and Medicaid Services (CMS) recently issued a Medlearn Matters (MLN) article SE1524 which provides further details on the ‘Probe and Educate’ Review audits it is conducting for home health agencies (HHAs). Earlier this year, CMS announced its plans to begin a ‘Probe and Educate’ strategy for reviewing Medicare home health claims related to patient eligibility (certification/re-certification) as outlined in the 2015 final rule for the home health prospective payment system (HHPPS). Agencies have since awaited specific instructions from CMS on the implementation process.

CMS says that Medicare Administrative Contractors (MACs) have begun sending Additional Documentation Requests (ADRs), as of October 1, 2015, and that the first round of claim reviews and provider education will conclude in approximately one year. CMS will direct the MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction. Based on the results of these initial reviews, the MACs will conduct provider-specific educational outreach. The MACs will deny each non-compliant claim and outline the reasons for denial in a letter to the HHA, which will be sent at the conclusion of the probe review. CMS also instructs the MACs to offer individualized telephone calls/education to all providers who have errors in their claim sample. MACs will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.

In addition to these educational outreach efforts, for those providers that are identified as having moderate or major concerns, the MACs will repeat the ‘Probe and Educate’ process for dates of services occurring after education has been provided. The MLN matters article includes a table that outlines the actions the MAC will follow depending on results of the ‘Probe and Educate’ review.