Home Health and Hospice Coalition Meeting Minutes: February 24, 2025

Meeting Date: February 24, 2025 
Meeting Time: 10 a.m. – 12 p.m. ET
Meeting Location: Virtual
Meeting Hosts: Tim Rogers, President and CEO; and Shannon Pointer, DNP, RN, CHPN, Senior VP, Hospice and Home Health Services and Professional Development Director, AHHC of NC and SCHCHA

Meeting Agenda

Review Choice Demonstration (RCD)

Question: Is there any information Palmetto GBA can share about whether there are any potential changes to the RCD program being considered by CMS, possible additional states added, or any other recent updates since our last coalition meeting?

Response: There are no updates currently.

Provider Enrollment

Question: When an administrative error is made in the processing of a provider enrollment application (the wrong name is tied to the application, for example), how can a provider get the situation escalated within Provider Enrollment?

Response: The agency should contact our customer service center to review and escalate the issue for resolution, if applicable.

Question: We have noticed continued delays in communication and processing time by provider enrollment. Can any information be shared on expectations for provider enrollment turnaround times? Also, it would be most helpful to have a resource easily accessible on timelines that help to better understand the intersect between what happens at the state level and what is happening with Palmetto GBA when providers have questions or feel they are experiencing delays within this process.

Response: Provider Enrollment process all applications in the order they are received. We are still working to resolve applications pending in 2024 by March. All escalations should be sent to the customer service center for immediate assistance, and they will escalate to PE thru our internal processes.

Question: Is Palmetto GBA seeing an increase in provider enrollment applications for home health agencies? If so, are there particular states where you are seeing this?

Response: We do not have any data to support increase in HH applications.

Claims Payment Issues Log (CPIL)

• Home Health Reason Code 19963, Notice of Admission Not Found: Some HH claims with admission dates prior to August 23, 2023, and service 'Through' dates approximately within 18 to 24 months of the admission date continue to edit for 19963 in error. Palmetto GBA is identifying those claims that are impacted and are creating new corresponding NOAs (as described in the October 6, 2023, update) in FISS on a weekly basis. Once the new NOAs are processed, we will release the 19963 claims back into processing. This issue should not impact HH claims with admission dates after August 23, 2023, or claims with 'Though' dates more than 24 months from the admission date.
   
• Some Home Health Claims Editing for Reason Code 37257, Federal Information Processing Standards County Code Missing or Invalid: For some 2025 HH claims, the HH Pricer is returning reason code 37257. This reason codes notes that the FIPS County Code is missing or invalid. This is occurring for HH claims that changed from urban CBSA in calendar year 2024 to rural CBSA in 2025. CMS stated the corrected Pricer should be able to be tested by the MACs later this week. 
   
• HH Reason Code U537I, no open HH admission on file: The RC for this issue is U537I “The FROM and THROUGH dates on the HH claim fall outside of an HH Admission period for the same provider.” CWF can only hold the 36 most recent periods of care on HHEH for any beneficiary. Periods that precede the most recent 36 will be dropped off the file and will not be retrievable online. The admission period drops and the claims for periods 37 and later cannot find that period and RTPs the claims. Bypassing this RC code did not work.
   
• Home Health Review Choice Demonstration (HH RCD) and Outpatient Department Prior Authorization (PA) Unique Tracking Numbers (UTNs): The S.C Region of Fiscal Intermediary Shared System (FISS) is experiencing delays in creating and updating home health RCD and Outpatient Department PA UTNs. The pending UTN will cause the claim to RTP with reason code C5461 or C5463. This issue mainly affects UTNs receiving a decision from January 23–24, 2025. Provider Action: Once providers receive the UTN with a decision, please wait 2 business days before sending the claim. If providers receive reason code C5461 or C5463, please wait two business days before resending the claim for processing.

Appeals

Question: We understand that the RAC, Performant, has at least temporarily stopped applying § 484.55(a)(1) as a requirement for payment. Palmetto GBA may be seeing appeals filed by providers, though, for past denials. Has Palmetto GBA received any guidance from CMS regarding the application of the requirement for the appeals process?

Response: There has been guidance from CMS regarding this topic.

Medical Review

Post-Pay TPE

Question: Most TPE is prepay. For what types of situations is post payment TPE applied?

Response: Please refer to IOM 100-08,Medicare Program Integrity Manual, Chapter 3, Subsection 3.2.5 (PDF). Targeted Probe and Educate (TPE). TPE reviews can be either pre-payment or postpayment and involve MACs focusing on specific providers and suppliers that bill a particular item or service. There is no specific evaluation to determine prepay and post pay review.

Question: Is the same process followed for post-pay TPE? 

Response: All process related to TPE is the same. The difference is based on the type of payment associated with the review (prepay is prior to the claim being paid and post pay after the claim was paid).

Question: if a provider advances to Round 2 of a post-pay TPE, are only claims that were submitted and paid after the round one education targeted for the second round?

Response: Yes.

Question: Is there any information that can be shared with the Coalition about reviewer training or qualification requirements?

Response: All HHH Clinical reviewers hold a Registered Nursing degree.

Question: Is there any information on how long Palmetto GBA leaves resources accessible, like educational offerings and training, and how long are they allowed to remain on locations such as social media, or within the Palmetto GBA web page?

Response: Resources are reviewed periodically to evaluate if the resource is current, correct and relevant. The resource will remain if it meets those criteria, if not it will be either updated or removed.

Question: We would like to review any updates related to the Palmetto GBA article on active medical review list for home health and hospice: 

Response: Here is the active medical review list: JM Parts A, B, Home Health and Hospice Active Medical Review List.

Question: When hospices recognize that documentation does not support hospice days of care, the claim is submitted with coding, including code 77, to indicate that the days are non-billable. This may include all or some of the days on the claim. Are edits in place to prevent such claims from being part of TPE ADRs? 

Response: For certain edits there are things put in place to exclude certain factors, and we do take things into consideration when creating audits. If the entire claim is non-billable, those ADRs are generally released.

Question: We know there is the PPEO (Provisional Period of Enhanced Oversight) edit for new hospices in Texas and there were some results of that edit released back in November. Is there any information Palmetto GBA can share about what more to expect in the way of PPEO TPE audits other than the new hospice edit?

Response: There is no new information related to PPEO, but Palmetto GBA wants to specify that PPEO and TPE are two separate types of review.

Question: What should the provider expect as far as a timeline goes from the time a round is finished to when education becomes available, and the next round begins?

Response: All timelines are dependent on the situation and the audit the provider is under. Sometimes there is a backlog of education based on the need of post probe calls conducted with providers. Some providers opt to bypass education which will speed up the process, but typical timeframes for education after results would be within two weeks for a nurse to contact the provider for educational call.

Question: We have recently learned about providers who have been put onto a fourth round of TPE. Is there any information Palmetto GBA can share about whether any providers have failed a fourth round and, if so, what actions came afterwards?

Response: Palmetto GBA cannot share specific info in related to provider results or activities after fourth round of TPE, it would be similar to previous rounds where providers are subject to additional probe reviews or recommendations to the RAC/UPIC or other CMS directives.

Question: We have heard from someone that they found an equation from the NIH for calculating BMI based on mid-upper arm circumference for our non-weight bearing/bed bound patients who cannot stand on a scale. It is: BMI= -0.042+0.873 x MUAC (cm) Would this be an acceptable measure for use, when combined with other clinical indicators, to support hospice eligibility?

Response: Palmetto GBA will review all clinical documentation utilized by the hospice to determine six months prognosis. Palmetto GBA does not require any particular type of measurement, and our general guidance is that more information is better.