Eli's Hospice Insider

Published on Thu Jan 17, 2019 PDF

See the TPE probe details.

HHH Medicare Administrative Contractor CGS reviewed two hospices under the Targeted Probe and Educate probe for Length of Stay with Non-Oncologic Diagnosis (edit 5D000), as well as one hospice each under these three probes:

• LOS greater than 180 Days (edit 5D002),
• LOS >120 Days (edit 5D003), and
• LOS in LTC, NF or SNF (edit 5D004).

The five hospices completing review were located in four states — Delaware, Maryland, Missouri, and West Virginia. The reviews in the most recent quarter were in the first two states, according to the MAC.

All of the review results from the most recent quarter fell into the significant risk category, meaning reviewers determined a 51 percent or higher error rate for claims reviewed, CGS reveals. But for the entire time period since Oct. 1, 2017, 80 percent of the results were in the significant risk category, while 20 percent were in the moderate risk (25 to 50 percent error rate) category.

CGS lists only two denial reasons for the quarter ending Sept. 30: “terminal prognosis not supported” and “MD services not medically necessary.”

Of those top denial reasons, terminal prognosis not supported accounted for an overwhelming 96 percent of the TPE denials, CGS reports.