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HPS reported recently regarding continued Targeted Probe and Educate for Home Health agencies. This is to clarify that the CMS expansion on Targeted Probe and Educate is for Home Health and Hospice and will be effective 10/1/2017. This is referred to as Targeted Probe & Educate (TPE). This review will include targeted medical review and education along with an option for potential elevated action, up to and including referral to other Medicare contractors including the Zone Program Integrity Contractor (ZPIC), Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), etc.

The goal of 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.

Highlights of TPE

  • 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
  • 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

  • Providers targeted for TPE will receive a notification letter about the upcoming 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.
  • Provider nonresponse to medical records requests will count as an error.
  • MACs may conduct a “related claim review” of services related to a denied claim and such reviews may be conducted outside of the TPE process.
  • The TPE process does not replace or change appeal rights.

Both Home Health and Hospice should make sure that you have an organized process of checking for ADRs and make sure that someone clinical is reviewing 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. One MAC has told us that a denial percentage of <33% would get the agency off of the TPE.

The following links will also assist in submission of ADRs.

Record Review Request Audit Tool

Palmetto Hospice ADR Checklist

Palmetto Home Health ADR Checklist

NGS Home Health ADRs

NGS Hospice ADRs

CGS ADR

Our targeted probe and educate consulting team would be happy to assist with reviewing charts that have been selected for ADR reviews or answer any additional questions you may have. We are currently assisting agencies across the country through TPE.