CMS to Conduct Probe and Educate Reviews for Patient Eligibility for Home Health Services
Tuesday, June 2, 2015
by: Visiting Nurse Associations of America

Section: Public Policy and Advocacy


by stacie
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CMS has announced that it will conduct pre-payment "probe and educate" reviews on a small sample of claims from each home health agency. The purpose of these reviews is to ensure that home health agencies understand the patient eligibility criteria and have sufficient documentation to demonstrate that the patient meets the criteria. The criteria include that the individual is homebound, is in need of skilled services, and has had a face-to-face visit with an appropriate provider. While the intent of these pre-payment audits is education, CMS retains the right to withhold payment for any claims for which the documentation does not provide sufficient evidence that the patient is eligible for home health services.

CMS has posted the following information related to these reviews on its website. CMS will publish additional information via its manuals in the coming weeks.

  • Home Health Medical Review

On Nov. 6, 2014, The Centers for Medicare & Medicaid Services (CMS) issued final rule CMS-1611-F, Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule. The HH PPS final rule (79 FR 66032) finalized a change that, beginning, Jan. 1, 2015, requires home health agencies (HHA) to obtain documentation from the certifying physician's and/or the acute/post-acute care facility's medical record for the patient that served as the basis for the certification and eliminates the face-to-face encounter narrative as part of the certification of patient eligibility for the benefit. Home health agencies should obtain as much documentation from the certifying physician and/or the certifying acute/post-acute care facility as they deem necessary to substantiate that the home health patient eligibility criteria have been met. Home health agencies are required to provide this documentation to CMS upon request.

  • Probe and Educate Reviews

CMS will conduct pre-payment reviews of home health claims for episodes beginning on or after Aug. 1, 2015. CMS contractors will conduct these reviews using a Probe and Educate strategy through an end date to be determined. The purpose of this Probe and Educate process is to ensure that HHAs understand the new patient certification requirements. Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about Oct. 1, 2015.

  • Probe and Educate Process

CMS plans to provide additional details and information on the Probe and Educate process shortly.

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