Targeted Probe and Educate is a major issue that makes Home Health and Hospice agencies anxious.

Targeted Probe and Educate was reenacted on September 1, 2021.  Home Health and Hospices across the Nation have been upset with why CMS felt it necessary to continue medical review in the middle of a Public Health Emergency. The reality is that medical review continues, and Targeted Probe and Educate is the current process that Medicare MACs are going through to conduct medical review in the pre-payment model.

The Process of TPE

You will first receive a letter explaining what the Targeted Probe and Educate process is, what is going to take place, and in most cases, tell you why you are being audited. This differs from many of the Medical Review Contractor’s processes.

Between 20 and 40 claims will be pulled for review. That range is the same whether you are a Home Health or Hospice agency. Once those claims are pulled, and you have submitted them for review, the Medical Review Contractor has only 30 days to review the charts and provide a response. Once they have completed the reviews in that round, you will receive a letter providing your results and a calculated denial percentage.

Failing a Review and How to Prevent It

Failing means your denial percentage is greater than your Medicare MAC’s allowed denial percentage. If you have failed, you will then be put into the next round of review. There are up to three rounds with Targeted Probe and Educate. If you fail all three rounds, you will likely be referred to the OIG, CMS, or one of the Medicare contractors for additional medical review.

It is important to have a clinical staff member, or someone from the outside, reviewing charts and scrutinizing every entry to verify that the packet has been accurately put together. It needs to be demonstrated in documentation and in a cover letter, exactly what you want the Medical Reviewers to see in the chart.

Clinicians get tired of hearing that you need to “paint the picture” with clinical documentation; however, Medical Reviewers can’t see or visit the patient, so the documentation is their only source. If the documentation is not specific enough to meet the Medicare requirements, those Targeted Probe and Educate reviews will be difficult.

The person compiling the chart must have clinical knowledge of how to deal with ADRs, assemble the chart with a table of contents, and be confident in their submission of appropriate documentation. If you find yourself in one of these reviews, be conscientious of timely filing and be cooperative with the reviewers.

Healthcare Provider Solutions has assisted agencies nationwide through the Targeted Probe and Educate process. Please let us know if we can help your agency.