Agencies facing claim review by CGS struggled with medical necessity under the latest round of Targeted Probe and Educate (TPE) results for January to March 2024.
The Medicare Administrative Contractor in 19 states and territories noted it has three TPE programs operating, primarily targeting medical necessity for 17 codes: I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, I25.10, N39.0, J18.9, or I87.2. They’re also doing prepayment review for new providers that have submitted at least 50 claims.
Of 27 probes completed, 17 providers were found non-compliant and advanced to the next round.
Overall, 26.6% of total denials were due to skilled nursing not being medically necessary.
The top 5 denial reasons were:
- Skilled nursing not medically necessary: 26.6%
- Initial certification invalid: 18.2%
- Therapy visits not medically necessary: 17.3%
- F2F missing/incomplete/untimely: 16.1%
- Medical records not received: 6.8%