Hello, everyone, and welcome to our Monday Minute.
Today I’d like to talk with you about Targeted Probe and Educate, specific to hospice and what we have been seeing happen there. For both home health and hospice, the Targeted Probe and Educate review process was put in place October 2017. It was put on hold in March 2020 when the Public Health Emergency began and then came back in September 2021. We have seen a huge influx of medical review focused specifically on hospice, which includes Targeted Probe and Educate, since September 2021.
For those of you who have not experienced Targeted Probe and Educate (TPE), TPE includes that the Medicare MAC conducts the reviews and will send you a letter telling you that you have been targeted. For hospice, they are very specific about the reason why you have been targeted. Many times, it’s a result of them reviewing data analysis, your PEPPER reports, your ADR Medical Review history, or another reviewer has been in your charts and has said they need to be looked at. Regardless, it typically will tell you the reason. Common reasons include long lengths of stay, non-cancer diagnosis with long lengths of stay, a lengthy average day for GIP patients, etc. When they give you a very specific reason as to why you’ve been targeted, they will only pull charts to review that are specific to that target reason. Because of that, you might have very few patients currently on service that meet the criteria for the reason you’ve been targeted, in which case it could be an extended period of time to get through this audit process.
They have to pull at least 20 claims, for the audit to be complete, they can pull as many as 40. They have only 30 days to review the chart once you have submitted the entire chart. Once complete, they will then send you a letter giving you a determination and making a denial percentage calculation. If your denial percentage is above the accepted denial percentage for your Medicare MAC, you will move to round two, after they have done an education call and waited 45 calendar days to start that next review. The same process will take place in the next review. If you fail round two, you will then participate in round three. If you fail round three, you are likely to be referred to the OIG for additional review, UPIC audit, or a SMRC audit. You need to ensure that if you receive a letter for Targeted Probe and Educate that someone in your organization is focused on making sure that those charts are clinically reviewed, that the charts are sent in very good shape and that everything that they have requested is in place and there is a cover letter that has been put on the front of the packet to lead the reviewer through the chart to assist in finding the correct information. Make sure that it is complete and submitted in a timely manner.
Hospices are currently under scrutiny, regardless of the Medical Review contractor that’s calling for the reviews, we are convinced, is a result, of the focus that the OIG has put on hospice of late. Understanding that one of the things that the PEPPER reports is revealing are high percentages of Medicare Part D payments being made on your beneficiaries’ behalf, even while a patient is in hospice and the OIG is extremely concerned about that. The PEPPER reports could also be triggering the Targeted Probe and Educate reviews.
We hope this helped a little bit today. If you need assistance with Targeted Probe and Educate don’t hesitate to reach out. We are very excited about seeing many of you this summer in live conferences across the nation. We hope to see you there. We will include links to Targeted Probe and Educate for each of the Medicare MACs in this minute and hopefully that will assist you in understanding more fully what you have been subjected to or could possibly be subjected to if you have not already. We hope you have a fabulous week and see you soon.