To:       NHPCO Members
From:  NHPCO Health Policy Team
Date:   May 17, 2012

Concerns about Palmetto GBA and the ADR Process

Summary at a Glance:
In recent weeks, NHPCO and representatives of the Hospice Coalition met by conference call with Palmetto  GBA about the recent ADR medical review process.  The following is a summary of our meeting with Palmetto GBA and their responses to our questions and concerns about the process.

From Palmetto GBA:
Thank you for your willingness to discuss the Coalition and NHPCO’s concerns regarding Palmetto GBA’s recent review of medical records.  We are very thankful for our strong partnership and are appreciative of our open dialogue.

Provisional Payment: 
As we discussed, the completion of medical reviews took longer than anticipated and caused some claims to age beyond customary processing time frames.  Therefore, Palmetto GBA released for provisional payment hospice claims for which Palmetto GBA had the medical records in house for more than 60 days. Claims that were provisionally released may be identified by a notation found in the Direct Data Entry (DDE) system. We have placed remarks stating “Provisional Release” on page seven (7) of the released claims.

Adjustment and Recovery of Overpayments: 
Now that the claims have been provisionally paid, we will continue the record review process and will make a formal determination based on the records already submitted.  If our review determines the claim is payable, no further action will occur. If our review results in a denial or payment reduction, Palmetto GBA will perform an adjustment and recover any overpayments.  For any denial or reduction, the provider will receive a remittance advice informing them of the decision. Appeal rights will be available for these claims.  

Technical Denials: 
If your members received technical denials during the review process where the documentation was clearly missed by the medical review staff, please contact the Medical Review voicemail box to relay your concerns.  The voicemail box is 803.763.7491.  We will return your call within two business days.

Accelerated Payment Option: 
If your members ever experience financial hardship due to issues outside the provider’s control, they may be eligible for an accelerated payment. Accelerated payment criteria and request instructions are on the Palmetto GBA website.

Monthly Billing for Hospice Claims: 
As we relayed to you during our call, we discovered during the review process that some hospices have been billing in weekly or bi-weekly increments.

CMS requires monthly billing for hospice claims.  We posted an article to our website and we contacted the top 50 providers to educate them. 

The Hospice Coalition is a group of individuals that primarily represent the 16 state hospice organizations that fall within the J-11 Palmetto MAC region.  The Coalition has been meeting with Palmetto GBA for more than 17 years.

Questions can be directed to NHPCO at regulatory@nhpco.org.