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Targeted Probe & Educate began on 10/1/17 and is full speed ahead. This review includes targeted medical review and education along with the potential of elevated action toward the agency, 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. This elevated action could take place if the agency is not meeting the standards laid out by the Medicare MAC.

Palmetto GBA is still not sending out Hospice TPE Letters and have said it will be a delayed implementation for them. They are sending out Home Care TPE letters and some agencies are finished with round one already. Both CGS and NGS are issuing letters for both home care and hospice. We also now know that Palmetto’s denial percentage is 20%, NGS is 15% and CGS is 25%. This is the denial percentage that you must be under, in each round, in order for you to be removed from the targeted probe.

HPS has also discovered some nuances with TPE that we did not expect nor have we experienced in past ADR reviews. CGS is being very specific with the claims that they will be pulling for review in some cases. NGS, in a letter we have seen, specifically states the number of charts they are going to pull vs. providing the range of 20-40.

CGS Examples:

  1. A hospice received a letter that explained why the hospice had been targeted and then it stated that they would be pulling 20-40 charts billed with the following: “A length of stay greater than 730 days and a from date of service of October 1, 2017 or after.”
  2. A home care agency received a letter stating: “ A prepayment review has been initiated to probe a sample of claims”
  3. A home care agency received a letter stating: “ A prepayment review has been initiated to probe a sample of claims billed with a from date January 1, 2018 or after”

NGS Examples:

  1. A home care agency received a letter that stated: “A prepayment review has been initiated to probe a sample of 20 of your claims for home health services.”

The TPE letters that agencies are receiving typically have statistics, etc. to show why the agency was selected. Some of the letters we have reviewed include the following reasons for being selected:

  • Long Length of Stay
  • NonResponse to Previous ADR/Probe & Educate Requests
  • High Denial Percentages on Past reviews

Tips for Responding:

  • Assembling the charts should be similar to publishing a book.
    • There should be a cover letter (preface),
    • table of contents,
    • the chart should be in clear concise date order, including all orders, plans of care, OASIS, HIS, IDG/IDT meetings, communications, actual visit notes and clinical summaries (see links below)
    • there should be specific notations to point the reviewer to the key items in review, such as Face to Face Encounter documentation, support for homebound status, skilled need, terminal condition, etc.
    • a clinician should review the chart prior to submission

CGS Documentation Checklist for Home Care

CGS Preparing Your Documentation for Hospice ADR Review

Palmetto Responding to a Hospice ADR

Palmetto Responding to a Home Health ADR

NGS Hospice Documentation Checklist

NGS Home Health Documentation Checklist Suggestions

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 – Generally, during the TPE the Medicare MACs are not allowed to pull ADRs for any other reason. This point is that if the MAC discovers questionable findings they may expand the audit on your agency without having to immediately refer the agency to a different contractor.

The TPE process does not replace or change appeal rights. This is comforting. If agencies are denied by the Medicare MAC for charts pulled in TPE, the agency still has all appeal rights that ADRs have always carried. However, even if the results are overturned at appeal, the agency denials are still counted in the denial percentages.

All three Medicare MACs have the capability of electronic submission of medical records for review. If your agency has not yet enrolled in the electronic submission of records that should be investigated. The acceptance of the record timely is much easier to handle and prove if questioned by the MAC when submitted electronically.

HPS is ready and willing to assist agencies that are subject to Targeted Probe and Educate. HPS has a team of reviewers that have assisted agencies through numerous levels of review including ZPIC extended reviews, ADRs and RAC audits. HPS is currently assisting multiple agencies through TPE. LEARN MORE or CALL US today.