This Minute will take you through a quick recap of the Targeted Probe & Educate framework as the program is being reinstated!
Hello, everyone and welcome to our Monday Minute. Today I want to talk to you about Targeted Probe and Educate. Targeted Probe and Educate is a very focused Medical Review program that began in Home Health and Hospice in October 2017. In light of the public health emergency that went into effect in 2020, Targeted Probe and Educate was put on hold at the beginning of March. When that occurred, all of the claims that were currently in ADR status, as a result of TPE, were released to be paid. Those claims were subsequently processed and paid by the Medicare program. It has been on hold since and now we are in August 2021, where a few months ago, they reactivated post-payment reviews. So all of the reviewers, UPIC auditors, etc. Could begin post-payment reviews again, prior to March 2020. Then in July 2021 they reinstated or said that the post-payment reviews could now be done for dates of service during the public health emergency. So that basically opened it up completely for all dates of service if the client has been paid. They mentioned when they reopened post-payment reviews that in the future Targeted Probe and Educate would be reinstated. That day has arrived! On August 12, 2021 a CMS memo was issued that said Targeted Probe and Educate is being reenacted. It does not give us any specific timeframe. So it does not say it’s going to start October 1st or December 1st, it just says it’s being reactivated. Our assumption is at this point that it will be reactivated now having been given no other date. So the reality is under Targeted Probe and Educate you’re subject up to three rounds of medical review. Those reviews are pulled as you bill a claim, so they are not post-payment reviews. They are pre-payment ADR reviews, and they are done by your Medicare MAC. This is applicable to both Home Health and Hospice, not anyone individually. Typically, when you are targeted, they will send you a letter to tell you they’re going to pull between 20 and 40 charts. Once they have made their selections, they will then review those charts, they have 30 days to review them and return a response. If your denial percentage is not less than the acceptable percentage for that particular Medicare MAC, you will be forced into a second round of review where they will repeat what they did in the first round and possibly a third round if you’re not successful in round two. If after round three, you have still not been successful in getting under their acceptable denial percentage, you could be subject to additional review by CMS contractors, typically the OIG, UPIC auditor, etc. So you really need to make sure you pay attention and get the charts into them clean so that you can get through this medical review in the first or second round at a minimum.
I want to thank you all for participating today. Make sure that you stay tuned to your state and national Home Care Association information. If you don’t get emails such as the one that I received today from CMS, you should go to the CMS site as well as to your state association sites and sign up for email notifications and newsletters, and information. You can never have enough information to get you through the things that are continuously changing. Thank you again for participating and we hope to be with you again in a live conference or on a webinar soon. Have a wonderful day.
If you have any questions or need assistance please contact us or go to targetedprobeandeducate.com