Targeted Probe and Educate (TPE) continues to present significant challenges for home health and hospice agencies as medical reviews become increasingly complex, time-consuming, and demanding. With growing documentation requirements and an increasing volume of medical review requests, it is more important than ever for providers to stay informed about changes that could impact their agency. Today, we’ll discuss two important TPE updates, including new reporting requirements for Medicare Administrative Contractors (MACs) and changes to the notification process that agencies need to be aware of.
Targeted Probe and Educate (TPE) is a medical review process in which your Medicare MAC notifies your agency that it has been selected for review. Whether you are a home health or hospice provider, your agency will receive a letter outlining the review process. As part of TPE, your MAC will review a minimum of 20 claims, with the possibility of reviewing up to 40 claims.
The TPE process can involve up to three rounds of medical review if your agency’s denial rate exceeds the acceptable threshold established by your Medicare MAC. For NGS/Wellpoint Federal, the acceptable denial rate is 15%, compared to 20% for Palmetto GBA and 25% for CGS. If your agency exceeds the applicable denial threshold, it will be moved into a second round of review. If your agency continues to exceed the threshold through the third round, it will be referred back to CMS, which could result in additional medical review, such as a Supplemental Medical Review Contractor (SMRC) audit or a Unified Program Integrity Contractor (UPIC) audit.
One of the most important updates is a positive development for home health and hospice providers. CMS has added language to the Medicare Program Integrity Manual requiring Medicare MACs to update their TPE results on a quarterly basis. These updates must include at least the top three reasons for claim denials identified during TPE reviews. While some MACs have routinely shared this information, the frequency of those updates has not always been consistent. This new requirement will provide agencies with more timely and consistent insight into the most common reasons for denials, helping them identify potential compliance concerns, address documentation deficiencies, and better prepare for future medical reviews.
Another important update involves CGS, which recently issued a memo addressing the TPE process. If your agency exceeds the acceptable denial threshold during the first round of review, you will be asked to participate in an education call to discuss the findings and areas needing improvement. Following that education call, there is a mandatory 45-day waiting period before the next round of medical review can begin.
In the past, CGS has sent notification letters to agencies informing them when their next round of TPE review was about to begin. However, CGS will no longer issue these advance notification letters. Agencies will still receive an initial letter when they are first selected for TPE. If your agency exceeds the acceptable denial threshold during the first round and completes the required education call, the next round may begin after the mandatory 45-day waiting period. Rather than receiving a separate notification letter, your agency will receive an Additional Documentation Request (ADR), which will signal the start of the second round of review.
We have confirmed with Palmetto GBA that there will be no changes to its current TPE notification process. Palmetto GBA will continue to send advance notification letters to agencies before the second round of medical review begins. However, at the time of this recording, we have not yet confirmed whether NGS/Wellpoint Federal will make any changes to its notification process.
If your agency is undergoing Targeted Probe and Educate, it is critical to have someone consistently monitoring for ADRs. You should also ensure that a qualified clinical professional thoroughly reviews each chart before submission. All documentation should be organized in chronological order, and agencies should carefully verify that they are submitting only the information specifically requested in the ADR.
Healthcare Provider Solutions offers webinars throughout the year covering important medical review topics for both home health and hospice providers. These educational webinars are included as part of the HPS Alliance membership, providing agencies with valuable resources to help navigate the medical review process.
Should your agency need any assistance in responding to a medical review of any kind, please don’t hesitate to reach out to HPS.
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