Since 2015 CMS has instructed Medicare Administrative Contractors (MACs) to request records for 5 claims from each home health agency within their jurisdiction to review on a pre-payment basis. For the time being, this practice (affectionately known as Probe and Educate) isn’t’ going anywhere.
2017 brings us to round 2 of the Probe and Educate program. Starting late last month MACs have begun sending Additional Documentation Requests (ADRs) and that this round of claim reviews and provider education will take about one year.
Although these “Probe and Educate” reviews have intended to be educational, they still could potentially result in serious consequences for non-compliant agencies.
Below and linked find a recent summary of the program from CMS’s publication MLN Matters.
Page 3 of the following article includes a table which outlines MAC actions following HHA probe reviews.
Probe & Educate reviews have applied to claims with dates of service beginning on or after 08/01/15. If the MAC denies one out of the five claims under review, it will send an education letter to the agency summarizing its findings and the process will be complete. However, if more than one of the five claims is denied, or if the agency fails to submit documentation in response to the request, then the MAC will send a “detailed” findings letter and repeat the review process with another 5 claims with dates of service on or after the date of the findings letter. The purpose of this second review will presumably be to assess the agency’s compliance with the MAC’s previous education efforts.CMS has directed the MACs to offer agency-specific education, like a one-on-one phone calls, with contractor medical review staff as part of the post-review education process. During such calls, the MAC will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.
MACs have continued the review process for delinquent agencies, implemented more extensive medical review audits on either a pre-payment or post-payment basis, as well as refered non-compliant agencies to a Zone Program Integrity Contractor (ZPIC) for investigation.