*URGENT INFO FOR HOME HEALTH MEDICARE PROVIDERS*

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Today in the Pre-Claim Review webinar conducted by Palmetto GBA, an announcement was made that Palmetto nurses performing pre-claim review would no longer “affirm” claims performed by NPs in the physician’s office or in the home IF the certifying physician was different from the NP on the plan of care and the patient was not a direct admit from an acute or sub-acute facility. The issue places immediate risk to all face-to-face encounters performed by NPs in Pre-Claim, Targeted Probe and Educate, or ADR reviews conducted by Palmetto.

Palmetto nurses are now issuing “non-affirming” ALL claims that do not meet the “revised interpretation” retroactively. This means that if a beneficiary was admitted in October 2024 and the face-to-face was performed by a NP in the physician’s office and the physician signed the plan of care, the agency will NOT get this claim affirmed unless the patient was admitted from the hospital.

The new interpretation by Palmetto has not been noticed formally by CMS or Palmetto nor is there any intent to grandfather in the prior interpretation to current reviews. In fact, during the webinar, Palmetto posted a portion of the federal CFR and the Medicate Benefit Policy manual that leaves out the 2020 revision that apparently created the interpretation problem.

The home health industry as a whole will be greatly affected by this interpretation change. Physician practices will also have to change internal procedures if the practice has NPs who perform F2F encounters. And, unfortunately, unless CMS steps in to provide further guidance, physician’s will not receive any updates on the issue. It will come from the home health community and the physician’s patients!

We anticipate legal action is going to be required to protect the home health industry and its patients who are at great risk from non-covered health care at the most vulnerable time of the year.