QIRT Alerts!

October 3, 2017

Regulatory Update: Targeted Probe and Educate Starts Now.

Filed under: home health — Quality In Real Time Blog @ 3:43 pm

Sometimes what you don’t know can hurt you. The MACs have their marching orders from CMS: find those providers that bill for “items/services that pose the greatest financial risk to the Medicare trust fund and/or have the highest claim error rates or billing practices that vary significantly out from their peers”. These orders will be carried out through a  targeted probe and educate (TPE) campaign.

What is different with this probe and educate? Volume for one thing. If your agency is targeted, you will be asked to submit 20-40 charts. Where they find errors/non-compliance, you will be invited to participate in a one-on-one educational session. Agencies with moderate to high error rates will continue on to the second round of 20-40 charts, and then a third.

If after three rounds there is still little improvement, an agency will be referred to CMS for additional action which could include 100% pre-pay review, extrapolation, or referral to a recovery auditor. Agencies showing sufficient improvement may be removed from the review process at any time.

If you’re targeted, be one of those organizations that shows improvement on the first round. Not sure what that means or what to do? Come to the ADR to Appeal Primer and learn from Joe Osentoski, one of the country’s leading experts on home health compliance.

We recommend you remain educated on this topic: the law does not excuse for ignorance.

October 2, 2017

Agency Action Alert – Targeted Probe and Educate Now Underway

Filed under: home health — Quality In Real Time Blog @ 3:40 pm

Phase three of CMS’s probe and educate is underway. The first wave of letters is in the mail. Your agency will be in this first round if you failed to respond to previous ADR requests, if you had two or more denials, if you were offered education but did not participate, or if your agency did not show improvement.

CMS asserts that through the Targeted Probe and Educate, MACs “will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” the agency said. But the MACs are combing through mountains of data from every single agency in the country and if your agency has errors, they will be found.

Many will be targeted, but few agencies are experienced enough with ADRs to provide the robust response that will be necessary when that letter arrives. Do not be caught unprepared.

Have questions about where to begin? Come learn from Joe Osentoski, one of the country’s leading experts on home health compliance. Attend the ADR to Appeal Primer and find out how Mr. Osentoski earned his reputation and his phenomenal 96% overturn rate at the ALJ level. Improve your agency’s chances of success with the Targeted Probe and Educate.

September 14, 2017

Are you prepared for CMS’ Targeted Probe and Educate Reviews? Did you know that starting this fall you could be sent ADR requests for 20 – 40 claims?

Filed under: home health — Quality In Real Time Blog @ 10:24 am
Round two of the 5 ADR Probe and Educate reviews is winding down in September, but most agencies are not out of the woods. The MACs are gearing up for Targeted Probe and Educate.
How do you know if your agency is on the Targeted Probe and Educate list? You are if you:
  1. Received two (2) or more denials during the five (5) ADR Probe and Educate.
  2. Received denials, but failed to participate in the education offered.
  3. Responded to the ADR requests, but failed to show improvement.
  4. Failed to respond to the 5 ADR request (along with more than half of all agencies).

Good news! These claims are not a lost cause. If you have denials with Reason Code 56900 and you are within the 120-day response window, QIRT can help you comply with these ADR requests. No response results in a guaranteed loss, but if you respond you still have a chance of payment.

What will happen if your agency is targeted? What do you do?
  1. Your MAC will send ADR requests for 20-40 charts – respond promptly.
  2.  After each review, education will be offered – participate in the program offered.
  3. Agencies that fail to show improvement will be referred to CMS for additional action, which might include:
    1. 100% pre-pay review.
    2. Extrapolation of findings to all claims.ADR and QIRT (1)
    3. Referral to a RAC or other auditing body.
Good news! Low error rates or “sufficient improvement in error rates” may get your agency off the hook for future audits.
QIRT’s best advice:
Contract with experts to complete your Targeted Probe and Educate, to ensure:
  1. Prompt and proper compliance with ADR requests.
  2. Full and proper payment of claims.
  3. Minimal impact on agency productivity – QIRT has processed thousands of ADRs, we know what we’re doing.
  4. Expert attention to the many moving parts of ADR response.
  5. You continue to focus on your agency’s most important work: patient care.
Have more questions? Join us for a full day seminar on ADRs. QIRT.com/Trainings
Or call 855.485.QIRT 
October Seminar:
Prepare for CMS’s Probe and Educate:
The ADR to Appeal Primer
Review and appeal processes can be overwhelming. QIRT can help. Join QIRT’s industry-renowned expert Joe Osentoski in Oak Brook, IL, for a simplified ADR explanation.
About our expert:

QIRT’s Director of Regulatory Reimbursement and Appeals Development is Joe Osentoski, BAS, RN-BC. With 20+ years’ experience, Joe has completed thousands of ADRs/appeals and hundreds of ALJ hearings dealing with all OMHA offices.

“Mr. Osentoski was one of the first non-attorney representJoe Osentoski.jpgatives to appear before me when I was an ALJ, and he stands head and shoulders above every other non-attorney representative. Mr. Osentoski…knows home health law, and prepares thoroughly. His credibility is beyond reproach.” ISBN 978-1-4834-5221-0. From “How to Handle Your Medicare Hearing” by retired US Administrative Law Judge Robert Soltis; Chapter 39, Recommended Representatives (p.140)

June 26, 2017

The Great 8 – Your Agency Steps to the CoP Transition Solution.

Filed under: home health — Quality In Real Time Blog @ 9:46 am
  1. Direct the change. Assign a transition leader, such as the administrator, a compliance officer, or a quality assurance manager, to be the change agent.
  2. Use the tools at hand. Talk to your EMR vendor right away to discover what is being done to aid compliance. Is quality assessment and performance improvement (QAPI) information being added to the system?
  3. Learn, then learn more. Require that the transition leader attend a formal training on the new rules as they are currently understood, and then attend another training after CMS issues interpretive guidance.
  4. Time-map your transition. Prep for the transition by creating a specific timeframe for compliance. This will look different for an agency with a 3,000-person census versus one with a 30-person census. What does it look like for your agency?
  5. Analyze to prioritize. Perform a full agency gap analysis that includes a review of the org chart, all policies, procedures, processes, programs, and each department to identify where compliance gaps exist.
  6. Education is the name of the game. Educate, support, and manage staff while necessary changes are being made. Include implementation meetings and special focus on areas that historically have been difficult within the industry, such as coordinating services with other types of providers.
  7. Know your agency. Assess board strengths and weaknesses and address appropriately to ensure they can meet new mandates, such as reviewing QAPI initiatives.
  8. Build a budget. The Congressional Budget Office estimated that implementing the CoPs would cost an industry-wide total of $293.3 million in the first year. How can your agency use technology to help control costs?

April 5, 2017

Time is on My Side: Getting Ready for the CoP Challenge

Filed under: home health — Quality In Real Time Blog @ 9:40 am

On Friday, CMS announced a delay in the new Home Health Conditions of Participation (CoP) until January 2018. That should come as no surprise to anyone since, as of today, we have no interpretive guidelines and surveyors have not been trained regarding the new Rule.  Just like in that Rolling Stones song “Time is on My Side”, CMS has given us the gift of time and we need to take full advantage of it.

This delay is welcomed by all who have actually read the entire 374-page document released by CMS in January of this year. It is important that every single agency in the US take full advantage of this reprieve as a time of preparation. It will take at least 6 months to prepare.

We all remember ICD-10 and the back and forth with CMS with delays and resets.  Compared to these new CoPs, ICD-10 preparation was much simpler. This new rule changes everything. It is more than a paradigm shift in policy and procedure. Experts call it a ‘sea change’ that is unprecedented. Compared to changes in conditions we’ve all experienced in the past (i.e. OASIS), this is revolutionary and will shake our industry as nothing else has.

Be sure, every person in your agency will be affected.  From the receptionist to your Board of Directors, this rule will change the culture in our industry and change the way we do business. It will no longer be ‘business as usual’.

Not so long ago, we had ICD-9 to ICD-10 transitioning challenges. Much of what we planned for that transition can clearly be used in our strategy in the shift to the 2017 CoPs. For instance, GAP analyses, extended training of ALL staff, budgeting, job description changes, etc. will all be necessary when taking this journey from where we have been comfortable with for decades.

The July 13, 2017 enforcement date originally proposed by CMS would have been almost impossible to achieve. We have been given the gift of time. We need to manage this time well and plan our course. Even six months will be a short time frame to achieve everything we need to do.

The January deadline is unlikely to change. Understanding of the Rule and implementing the associated staff training, policy and procedure revisions, and hiring need to begin right away. This is a radical shift from the way we currently function.

You will be able to meet this deadline – but you may need help. It will be important for you to watch for the multiple training sessions QIRT has scheduled.  We will be offering education and tools to help you through the process.

Arlene Maxim, RN

April 4, 2017

Pre-Claim Review (PCR) – Be Careful What You Wish For

Filed under: home health — Quality In Real Time Blog @ 12:44 pm

That was close, Florida.

Literally hours before implementation, Florida home care agencies received the news they were hoping for.  A long-awaited hold has been placed on pre-claim reviews (PCRs) in Florida and a pause has occurred in the state of Illinois. After months of laboring with a poorly prepared Palmetto in Illinois, agencies in that state can now take a deep breath and go back to original billing policies and procedures.

However, is this really a good thing? Like that old saying, “Be careful what you wish for”, this pause/hold could be an effort to take PCR in a different direction – perhaps a nationwide implementation. While the impetus behind PCR was an effort to detect fraud, it appears that discovering fraudulent activity was not accomplished. What became evident, however, is the lack of understanding many providers have regarding patient eligibility and admission/recertification processes. In particular, face-to-face requirements and medical necessity are not being met.

Many experts in the home health agree that this pause/hold could trigger an expansion of this program to states nationwide.

Documentation related to medical necessity and homebound status has been a challenge for agencies and physicians for decades. While we have only been dealing with face-to-face for six years now, it has been a struggle to gather the necessary documents indicating patients’ homebound status and need for services. CMS recognizes this.

MACs and other oversight agencies promoting PCR are lobbying CMS hard to keep it going. Agencies and a number of legislators seem to want it either re-designed in its current form or dismantled altogether. It is important that agencies take this time to re-train staff on documentation practices related to medical necessity and determining patient eligibility.

The CMS announcement indicated a 30-day pause. So, for now, we will wait.

-Arlene Maxim, RN

VP QIRT Program Development

March 31, 2017

Home Health PCR Suspension Announced Today!             

Filed under: home health — Quality In Real Time Blog @ 7:31 pm

Late Friday afternoon, CMS announced that effective April 1, 2017, PCR will be paused for Illinois at least for 30 days. In addition, PCR will not begin on April 1, 2017, in Florida, as previously planned.  This news follows a meeting with the new CMS Administrator, Seema Verma and several providers from both Illinois and Florida. Agencies are to stay tuned to QIRT Regulatory experts and their MAC for further development.

CMS Proposes Delay in the HHCoPs

Filed under: home health — Quality In Real Time Blog @ 6:30 pm

Our industry received a slight delay in the implementation of the Home Health Conditions of Participation. This proposed delay is to be effective January of 2018.  Providers should use this time to begin training on the new CoPs and to begin setting your agency up for compliance. Take this opportunity to attend QIRT’s two-day event on the new regulations to be held in Las Vegas at the beautiful Mandalay Bay, June 12-13, 2017.  Our regulatory experts are here to be your partner in success!

December 21, 2016

Probe and Educate Strategy Continues

Filed under: home health — Quality In Real Time Blog @ 2:25 pm

CMS Announces a Continuation of the Home Health Probe and Educate Medical Review Strategy

In the December 16, 2016 MLN Release (SE1635), CMS announced that Medicare Administrative Contractors (MACs), in conjunction with CMS, have initiated Round 2 of the Probe and Educate Strategy for home health providers. This will be effective on or after December 15, 2016. The original Probe and Educate Strategy was constructed following a significant change in the CY 2015 Home Health PPS Final Rule. For providers, the specific change surrounding the F2F included the removal of the narrative requirement for the certification of the patient for home health. The final rule included the new expectations for how the certifying physician, or NPP, could incorporate the reasons for home health into the accompanying medical record from either the physician or the facility. Lastly, it outlined allowances for the physician to use portions from the home health medical record in the certification.

The first round of the probe involved select agencies experiencing five additional document requests (ADRs). The feedback from the ADRs offered details on agency deficiencies, along with an offer to provide additional education. With this second round, the anticipated strategy conclusion is one year from the date it is initiated. CMS is directing home heath MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction, excluding those providers who had five claims reviewed in Round 1, with zero or one claim in error.

Whether or not your agency is included in this probe, QIRT has the solution to relieve ADR anxiety. Our expanded internal audit team is well versed in pre-claim audits. Let our team partner with your agency to provide a full audit of your claim-related data. Audits are conducted using the compliance measures CMS expects to be used when reviewing for medical necessity and full face-to-face compliance. Our team will audit the record and then partner with your team to educate on specific deficiencies. The QIRT compliance team can also prepare your already selected ADRs and submit to your MAC on your behalf. Call QIRT today for a discussion on how we can help!

Stefanie Woodrow


November 29, 2016

PCR Update: Palmetto Moving Forward Texas and Florida to Begin Testing eService Portal Now

Filed under: home health — Quality In Real Time Blog @ 4:16 pm

Last week, Palmetto announced that Texas and Florida providers could begin testing the Pre-Claim Review (PCR) eService Portal for submissions of PCR claims. This is the first indication that CMS intends to move forward with pre-claim review in the remainder of the five states previously identified. As of November 28, 2016, National Government Services (NGS) has nothing on their website to indicate how and when they plan to move forward with a plan for PCR.

Conventional thinking may lead agencies to believe that the lack of any information by NGS means there is nothing planned for Michigan and Massachusetts. QIRT experts would disagree. We believe NGS does not have the experience of the ramifications resulting from the rollout of the PCR process in Michigan and will not be prepared when CMS requires the process to begin.

On the other hand, we believe Palmetto has learned its lesson. It is more likely Palmetto is preparing agencies in Texas and Florida for entry into the PCR world in a more orderly fashion by allowing them to test the electronic system before another ‘mess’ occurs.

QIRT experts guess the remaining two Palmetto states (Florida and Texas) will soon receive the 30-day notice and will begin on January 1, 2017. The next following expectation is that NGS will come on board and begin the reviews soon after that date, perhaps in February or March.

As you have probably heard, the PCR process is reported to be improving. Affirmations have increased into the 80% range now. However, the number of provisional affirmations has still not caught up with the RAPs that have been submitted in Illinois. That bulk of RAP recoveries will take place on non-affirmed claims during the first week of December. Many agencies have yet to submit final claims. We will need to wait to experience the results of that fall-out.

The Michigan Association is working hard to keep agencies updated on the latest with PCR. We will notify you of any updates we receive on NGS’s plans to move PCR forward in Michigan.


Arlene Maxim


Next Page »

%d bloggers like this: