Targeted Probe and Educate Is Happening Now

The goal of the Home Health and Hospice Targeted Probe and Educate (TPE) is to reduce / prevent improper payments. The purpose of this expansion is to reduce appeals, decrease provider burden, and improve the medical review and education process.

This review includes targeted medical review and education along with the potential of elevated action toward the agency. Elevated action could consist of referral to other Medicare contractors including the Zone Program Integrity Contractor (ZPIC), Unified Program Integrity Contractor (UPIC), or Recovery Audit Contractor (RAC).

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HPS is ready and willing to assist agencies that are subject to Targeted Probe and Educate. Our targeted probe and educate consulting team has assisted agencies through numerous levels of review including ZPIC extended reviews, ADRs and RAC audits. We are currently assisting agencies across the country through TPE.










Highlights of Targeted Probe and Educate

All MAC medical record reviews are replaced with three rounds of pre-payment or post-payment TPE. If the provider’s error rate remains high upon completion of the first round, then the provider is retained for the second and, potentially, a third round of review.

Providers with a continued high error rate after three rounds of TPE will be referred to CMS for additional action. The MAC will select the topics for review based upon existing data analysis procedures. The claim sample size for each round of probe review is limited to a minimum of 20 and a maximum of 40 claims.

TPE processes include provider specific education that will focus on improving specific issues without allowing other problems to develop along with an opportunity for the provider to ask questions. Education will be offered after each round of 20 to 40 claims reviewed.

Tips for Success

All three Medicare MACs have the capability of receiving medical records for review by electronic submission. If your agency has not yet enrolled in the electronic submission of medical records, we recommend implementing that process as soon as possible. It is much easier to prove timely acceptance of the record when the record is submitted electronically to the MAC.

Both Home Health and Hospice should make sure that you have an organized process of checking for ADRs, including who has been assigned to clinically review the chart once it is assembled and that everything is included. Agencies really need to be successful in the first round and not be moved into the second round of review.

 

  • Providers targeted for TPE have been receiving a notification letter about the review and additional development requests (ADRs) will be used for the specific claims selected for review.
  • Providers should ensure that medical records are submitted promptly upon request.
  • Providers nonresponse to medical records requests will count as an error – this can trigger an automatic escalation of review of your agency and potentially a referral to one of the other contractors mentioned above.

Targeted Probe and Educate – What We Have Learned So Far

By Melinda Gaboury / Posted on: March 13, 2018 7 minutes to read

Targeted Probe & Educate began on 10/1/17 and is full speed ahead. HPS has discovered nuances with TPE that we did not expect nor have we experienced in past ADR reviews. This review includes targeted medical review and education along…

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Preparing for Hospice Targeted Probe and Educate (TPE)

By Katie Wehri / Posted on: October 31, 2017 9 minutes to read

As previously reported, the targeted probe and educate (TPE) process is replacing the medical review process used by Medicare Administrative Contractors (MAC).  Each of the three MACs – Palmetto GBA, NGS and CGS – can choose the topics for review…

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Targeted Probe and Educate

By Melinda Gaboury / Posted on: September 25, 2017 5 minutes to read

HPS reported recently regarding continued Probe & Educate for Home Health agencies. This is to clarify that the CMS expansion on Probe & Educate is for Home Health and Hospice and will be effective 10/1/2017. This is referred to as…

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MELINDA A. GABOURY

MELINDA A. GABOURY

CHIEF EXECUTIVE OFFICER

KATIE WEHRI

KATIE WEHRI

DIRECTOR OF OPERATIONS CONSULTING

DEDRA J. BRIGGS

DEDRA J. BRIGGS

CLINICAL PROJECTS MANAGER