Recovery Auditors (RA) and Zone Program Integrity Contractors (ZPIC)

Audits are an inevitable facet of the home health industry. Navigating through them can be daunting but recognizing the most common reasons why they occur and the entities who conduct them can offer understanding to the providers.

Top 10 ADR Denials – PGBA

1. Face to Face Encounter Requirements Not Met (5FF2F)
2. Auto Deny – Requested Records Not Submitted (56900)
3. Info Provided Does Not Support the Medical Necessity “M/N” for this Service (5F041)
4. Info Provided Does Not Support the M/N for this Service (5A041)
5. Physician’s Plan of Care and/or Certification Present-signed but not dated (5F012)
6. Unable to Determine M/N of HIPPS Code Billed as Applicable OASIS not Submitted (5FNOA)
7. Physician’s Plan of Care and/or Certification Present – No Signature (5F01)
8. MR HIPPS Code Change Due to Partial Denial of Therapy (M5CHG3)
9.  MR HIPPS Code Change/Doc Contradicts MO Item(s) (5CHG1)
10. No Plan of Care or Certification (5F023)

There have been issues with Palmetto denying because the Face to Face documentation was not present, however the Face to Face was submitted. The same has happened with other important information, such as the Plan of Care and the OASIS for the episode. Ensure that all pages are numbered and a Table of Contents is supplied to ensure that 1) there is less likelihood of the auditor stating it was missing and 2) it will be easier to appeal. The Texas Association for Home Care and other associations have been in
discussion with Palmetto to try to resolve this issue.

The requirement for the physician to date his/her own signature on orders has been in place for a time now. Stamped dates for the signature will not be accepted.

It is the RAs responsibility to review and correct PAST incorrect payments of providers. They are able to go back 3 years from the date the claim was paid and there are two types of reviews:

Automated (no medical records needed)
Complex (medical record required)

ZPICs can conduct interviews, onsite visits, and request medical records. They can also refer cases to law enforcement if they suspect fraud or abuse.

If you need assistance with audits, medical reviews, or appeals, please contact Selman-Holman & Associates, LLC. 940-383-2130 or 940-300-9974

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