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Probe and Educate Procedures for Medicare Administrators

CMS has recently issued Change Request 10249, which will expand Probe and Educate medical review procedures for all Medicare Administrative Contractors (MAC). These new procedures went into effect on October 1, 2017. As a Medicare-funded agency, here is some information that you should know about CR 10249.

New Targeted Probe and Educate Strategy

The MAC will be required to identify one or more topics and select providers to target for review. There will be three rounds of reviews conducted on pre-payments on a minimum of 20 to a maximum of 40 claims. A letter will be sent those selected to inform them of a Probe and Educate audit and provide instructions on how to respond to future requests for information. When a provider is found to be not in compliance, the MAC will provide one-on-one education through face-to-face, teleconferencing or online webinars to educate the provider on compliance. If after three rounds the provider is still receiving a high rate of payment denials, the MAC will defer to the CMS for additional action. If the provider is compliant or achieves compliance after the three rounds, the Probe and Educate process will cease.

Why Has the CMS Issued CR 10249?

Through pilot programs, the CMS has been utilizing Probe and Education for home health agencies that have been successful in educating their providers and have reduced improper payments. It is the intent of the CMS that CR 10249 will replace medical review activities currently used by MACs except for prior authorization, automated reviews and those directed by CMS. DCI provides the tools you need to keep your agency in compliance with CMS requirements. If your agency is targeted by a MAC for this new review, DCI software makes it easier to train your personnel internally and provide evidence of your agency’s compliance.

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