Tag Archives: claims denials

Palmetto GBA expands Probe & Educate initiative

Home health agencies in the 16 states served by Palmetto GBA Medicare Administrative Contractor could see a significant increase in the amount of records reviewed as part of an expanded Probe & Educate initiative.

Some agencies could be required to provide as many as 20-40 records on average instead of the five records requested for previous Probe & Educate reviews, according to Bobby Lolley, Executive Director of the Home Care Association of Florida.

“This review will be extensive, with 20-40 records on average being requested, not just another five records like in previous rounds,” Lolley said in an email to HCAF forum members this week.

Agencies subject to the significantly increased record requests are those which received denials of two or more records reviewed in an earlier round of the Probe & Educate initiative.  Some of those agencies did not receive specific instruction they were expecting from the MAC as part of the process because the Probe & Educate initiative was suspended earlier this year.

Lolley said all agencies in Round 2 can be subject to further review, even those agencies which did not complete Round 1 and receive one-on-one education from the MAC before that round was suspended.

Lolley said Palmetto provided the following  statement to a home health coalition request for clarification about agencies which did not receive one-on-one instruction : “Providers are being progressed if they did not request education on or before their due date. We have a number of providers that missed their deadline to request education, so yes, there is a chance that they have been progressed before they are receiving their education.“

Focus on the F2F

“Mac reviewers will be looking at the claims to ensure that agencies are in compliance with Medicare eligibility and payment requirements,“ said J’non Griffin, owner of Home Health Solutions.  “In Round 1, a substantial number of agencies had problems with the Face-to-Face.”

Additional concerns included a lack of specific orders for therapy and services, omissions and inconsistencies in documentation, but the Face-to-Face was one of the most troublesome areas for agencies, she said.

“Agencies which have not yet received training in the Face-to-Face should make doing so a priority,” J’non said.

J’non will offer an online audio training session titled “Make the Face-to-Face Count” next Thursday, July 13, reviewing valid and invalid F2F items pulled from actual charts, and discussing specific methodologies.  For details, click here.

Hospice agencies may be interested in an online audio training program titled “Improving Hospice Documentation,” presented by HHS Special Projects Director Heather Calhoun on Tuesday, July 11.  For details, click here. 

The 16 states in the Palmetto GBA area include Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, Illinois, Indiana, Ohio, Oklahoma, North Carolina, South Carolina, Tennessee, and Texas.

5 Essentials for Your Agency’s F2F Documentation

Can you list the 5 Must-Haves to insulate your home health agency against claims denials based on insufficient Face-to-Face Encounter (F2F) documentation?
Do you know how to incorporate missing elements of the F2F into the medical record?
If you blinked uncomfortably, you’re not alone. These questions are making many home health professionals nervous in the wake of voluminous claims denials after reviews under the Center for Medicare and Medicaid Services “Probe and Educate” Strategy.
Quality Checklist Infographic smaller f2f“It was mind-boggling to  learn early in 2016 that an astonishing 508 of 595 initial claims reviewed under ‘Probe and Educate’ had been denied, ” recalls Home Health Solutions LLC owner and president J’non Griffin.
Over the next few weeks, as reasons for the denials were publicized, it became clear that one of the biggest problem areas for home health agencies consisted of missing, invalid or incomplete documentation for Face-to-Face Encounters (F2Fs) between home health patients and physicians.


The F2F is mandatory for a patient’s home health certification. It ensures that all orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition. CMS requires that it occur within a specific time frame and address specific information about the patient.
Many agencies relying on forms to capture F2F information discovered that the forms they were previously using omitted details necessary under new CMS requirements.  Agencies also ran into trouble by relying on a physician’s verbal acknowledgement that the F2F had occurred, documenting the encounter and asking the physician to sign.
Some agencies did not understand the distinction between a certifying physician and the primary care physician. Others had not adequately established the patient’s homebound status in records submitted.
Correct procedures for F2F documentation require a brief statement by the certifying physician describing the patient’s clinical condition during the encounter, supporting the patient’s homebound status and the need for skilled services.
While it sounds straightforward, obtaining correct documentation from the physician, complete with required dates and signatures, all in a manner meeting CMS expectations, has proved to be an ongoing challenge for home health agencies.


If your agency is struggling with the nuances of F2F requirements, a small investment in training could pay off with major reduction in the risk of claims denials.
Home Health Solutions has just released a recorded training session in which HHS Director of Special Projects and Appeals Heather Calhoun breaks down each component, explaining in detail the five objectives of F2F requirements and specifically how agencies can meet each objective.  During the 90-minute presentation, she outlines three specific ways an agency can incorporate missing elements of the F2F into the medical record, makes clear the homebound status requirements which must be met, and establishes the difference between certifying and primary care physicians.
“You’ll love Heather’s down-to-earth approach to training,” J’non promises. “She has the hands-on experience needed for true peer-to-peer mentoring that goes an extra measure beyond the typical classroom approach.  She delivers all the information you need to understand F2F requirements, and she does it with a practical and engaging style that you’ll appreciate.”

Click here to check out the F2F training program now available  in the HHS Online Store.


The HHS  infographic below provides a quick checklist of the 5 essentials which must be in your agency’s F2F documentation.  Each is explained in detail in the HHS training program.

Quality Checklist Infographic F2F Take 5

Will your agency’s documentation stand up to scrutiny?

imageHome health agencies are heading into 2016 with some degree of apprehension about how well their documentation will stand up to scrutiny in a health market rife with regulatory risk.
Flawed documentation could threaten agencies with everything from legal issues to claims denials, and the compliance burden fattened up this month as new G Codes for home health and hospice took effect.
Curtailing risk requires not only an eagle eye approach to all records, but ongoing training efforts for staff whose notes are a crucial component in demonstrating quality care, according to J’non Griffin, owner of Home Health Solutions LLC.
“Agencies must sharpen their documentation skills, making certain their staff really understands how to capture critical information and integrate it with a cohesive, justifiable and well-defined care plan,” she says.
“At the same time, they’ll need to avoid the inconsistencies, omissions and errors that create red flags for auditors.”
Easier said than done? Maybe not. With the right focus on achieving quality, some guidance and a bit of practice, J’non believes, most agencies will successfully navigate these new complexities.
Home Health Solutions works with agencies of varying sizes to streamline operations and shore up bottom lines by identifying and improving weaknesses. Documentation is one of the areas where weaknesses are most likely to occur.
“Our clients often have unique needs and face different challenges, but when it comes to documentation errors, many of the same mistakes show up no matter how large or how small an agency is,” J’non says.

Four ways to clean up your documentation

With those recurring trends in mind, J’non and her HHS team members have identified four primary goals which any agency can use as a checklist in the pursuit of quality documentation:

1. Be defensive.

Your documentation is a legal record, and must stand up to examination by many sets of eyes.
“The quality of your documentation is the quality of care delivered to your patient,” says HHS Director of Appeals and Special a Projects  Heather Calhoun. “What is written there becomes the indisputable record of whether something was done, and why.”
The record will grow as your team members work from it and with it to develop and deliver patient care; each addition must not only be accurate and complete, for its integrity to be maintained, but must build on the other parts.
Eventually this record may well be seen not just by by auditors, but by licensing, accreditation and government reviewers — and could, in a case involving legal proceedings, even be viewed by judges or juries.
“It must be able to defend itself to each new pair of eyes as an error-free, easy-to-understand, complete record with all parts in place to show exactly how and why your agency provided quality patient care,” J’non says.

2. Be specific.

With auditors now able to pull out records of visits by type and ask specific questions, details have become more important than ever before.
Vague areas in records are the black holes of the home health field, costing agencies thousands of dollars, and must be bridged with clear, concise summaries showing cause, goals and intent as well as all specific actions taken.
“And the need for specificity begins at the very start of all care,” Heather says. Agencies must start each case by first establishing the medical necessity for care and continue to document each step in the process through the filter of why it was necessary.

3. Be realistic.

One of the most important skills agencies must master to meet new documentation requirements is goal-setting. Determining a realistic course of patient improvement within a 60-day window requires consideration of comorbidity and a comprehensive approach across all home health disciplines.
Holly Kolitz, HHS Quality Assurance Manager, describes the right approach as a careful balance of common sense and measurable achievement.
“Goal-setting is a very patient-specific process,” she says. “It’s very important to be realistic about what you can expect a particular patient to fully understand and achieve, as well as in selecting the parts of that process which must be captured in documentation.”

4. Be comprehensive.

Does your documentation work together to tell a comprehensive story about a patient, with each piece fitting together like an interlocking puzzle? The pieces must match on multiple levels, with each document both standing on its own merit AND integrating seamlessly with each of the other documents.
“This is critical to demonstrating cohesive continuity of care,” Heather says. “Inconsistencies in documentation can potentially cost agencies a great deal of money.”
In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

All this may sound like a tall order, but focusing on these four fundamental goals really can make a marked difference in the quality of your agency’s documentation procedures.
“And if your agency needs additional help to untangle new documentation requirements, HHS can provide the customized services you need to transition successfully into 2016,” J’non says.

Beginning tomorrow, the HHS team will take documentation practices a step further, breaking down each of the four fundamentals covered here with some specific strategies for each.

TUESDAY:  Think Like An Auditor (A Checklist of Common Mistakes)