Archive for February, 2013

February 7, 2013

Palmetto Medical Review Wave Coming Your Way!

The Palmetto GBA Medical Review department will perform a service-specific prepay complex review on claims billed for selected Home Health HIPPS codes. Prepay complex review means Palmetto will not pay your claim until the review is done. The Medical Review department identified the top 20 Home Health HIPPS codes, ranked by provider disbursement. They determined that there is a high level of denial amongst some of the most frequently billed HIPPS and will be conducting medical review on two specific HIPPS codes with the highest claim count denial rate: 2CGK* and 1BGP* (last character of the HIPPS code doesn’t matter in this medical review).

My recommendations: 1) Design a report so that you know which episodes include the two HIPPS codes. 2) Review those charts carefully prior to sending the claim for documentation to support medically necessary care.  3) Call Selman-Holman & Associates, LLC if you’re not sure whether documentation is complete. Your HIPPS code may be incorrect, and if is not, you need to correct your OASIS (according to guidance provided by CMS), which means that you may also have to correct other items as well.

If you receive a request for the medical record, remember you have 30 days to submit the requested medical record information so time is of the essence (you’re not getting paid in the meantime). We can help you with that also.

When the claim is finalized, Palmetto will pay the claim in full or part, or deny. If you disagree with the decision, you may request a redetermination within 120 days of the determination (date on the remittance advice).

Completed review results will be posted to the Palmetto GBA website. Individual providers with significant denials may be contacted for one-on-one education.