Earlier this year, Palmetto GBA announced new medical prepay audits based on certain HIPPS codes that have the highest denial rates. While they have internally identified the top 20 HIPPS groupings with the highest denial rates, they have currently published and set up pre-pay audits for two code groupings. When an End of Episode (EOE) claim is submitted using one of these two HIPPS groupings, Palmetto GBA could place the claims into ADR status and providers will be required to submit additional documentation from the chart in order for a payment determination to be made.
In response to this announcement by Palmetto GBA, HEALTHCAREfirst developed Business Intelligence reporting that will enable home health agencies to identify and monitor episodes that will be audited upon EOE submission. Agencies can then focus on the charts that make up these at-risk claims, ensuring that their documentation is accurate and complete should the claims go into ADR status.
In addition, HEALTHCAREfirst has expanded the HIPPS code groupings beyond the two identified by Palmetto GBA to include ten additional code groupings that may be subject to audit, based on internal statistics. This assists home health agencies in preparing for potential upcoming audits, regardless of their MAC. In addition, Episode Master, the automated QA tool within Business Intelligence has received a number of enhancements that include more detailed messages and suggestions to help protect agency review and ensure documentation is as accurate as possible due to increased industry scrutiny. These edits focus on many of the issues that typically result in take backs when agencies are targeted.
“Like never before, home health agencies must know where their money is at all times in order to avoid interruptions in their revenue cycle. These new enhancements are important additions to our Business Intelligence analytics tool, providing the information needed to make informed business decisions before it’s too late,” said Stan Bell, Vice President of Product Management.