“Face-to-face encounter requirements not met” and “no plan of care or certification” accounted for half of all denials in pre-payment reviews by Palmetto GBA in the last three months of 2022.
The MAC servicing 16 states released the Targeted Prove and Educate (TPE) results in April.
“No plan of care or certification” includes denials due to the physician’s signature missing on the certification or recertification.
The rest of the top five (with the percent of total denials) included:
- 13% — The Documentation Submitted was Insufficient to Support that the Skilled Nurse Service(s) Billed Was/Were Reasonable and Necessary
- 12% — No Physician’s Order for Services or More than Ordered
- 4% — Dependent Services Denied