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The Current State of TPE and How to Avoid Common Claim Denials for Home Health and Hospice

Written by Leslie Heagy, RN, COS-C
Posted in Survey Preparedness
April 6, 2023

 

THE CURRENT STATE OF TARGETED PROBE AND EDUCATE (TPE)

The Centers for Medicare and Medicaid Services (CMS) initiated the Targeted Probe and Educate (TPE) Medical Review audits in November 2017 to improve the medical review/education process, reduce appeals and decrease provider burden with the goal to reduce and prevent improper payments.

TPE Medical Reviews for both Home Health and Hospice agencies are in full force after being resumed in September 2021 following a pause at the beginning of the Public Health Emergency (PHE). Home Health and Hospice providers continue to have the same issues resulting in claim denials, with many agencies advancing to subsequent rounds for further review.  Home Health continues to have a high percentage of claim denials around the certification requirements, face-to-face encounters and documentation not supporting medical necessity/skilled need. The number one reason for claim denials for Hospice continues to be documentation not supporting the six month or less terminal prognosis. Home Health and Hospice agencies MUST be proactive to avoid the negative financial impact of medical review. It is imperative to have a system in place to ensure compliance with the Medicare conditions of payment, including documentation to support medical necessity and the certification requirements required to avoid claim denials.

THE PROCESS OF TARGETED PROBE AND EDUCATE (TPE)

Agencies will first receive a notification letter from your Medicare Administrative Contractor (MAC) explaining the TPE process, and why you are being audited.  The individual MACs – Palmetto GBA, NGS and CGS determine the criteria that will be used to target home health and hospice providers for a TPE audit. This determination is based on data analysis of paid claims that identify areas with the greatest risk of inappropriate payments that results in the specific active medical review edits used for TPE. One of the top data sources analyzed is the Program for Evaluating Payment Patterns Electronic Reports (PEPPER).  If your agency falls within the edit criteria, you may be selected for a TPE Medical Review audit.

Once selected for TPE, you will begin receiving Additional Documentation Requests (ADR) for claims that meet the edit criteria. A minimum of 20 to a maximum of 40 claims will be requested for each TPE round. Once the claims are identified as an ADR and you have submitted the documentation for review, the MAC will have 30 days to review the documentation submitted and provide a response. At the end of each round, you will receive a letter providing your results and a calculated denial percentage that is used to determine whether you will be going to the next round of TPE.  To avoid advancing to the next round of TPE, the calculated error percentage at the end of each round must be less than the percentage set by the MAC:  CGS 25%, NGS 15%, Palmetto GBA 20%.

If you have failed the first two round and you fail the third round, you will be referred to CMS for further action. The decision letter will include instructions on how to schedule an education call for the purpose of receiving education related to the claim denial reasons received during the round. The next round of TPE, if needed, will begin 45-56 after the education call, allowing time to implement the education provided & correct errors from the previous round.

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TOP ACTIVE MEDICAL REVIEW “EDIT” REASONS FOR TPE

Hospice:

  • Length of Stay greater than 730 with non-cancer primary diagnosis
  • Q-Codes reflected on the claim for hospice services in a nursing facility (Q5003 & Q5004)
  • New Providers who have submitted at least 50 claims.

Home Health:

  • Home Health Medical Necessity – claims with 2 to 6 visits and select diagnosis codes
  • Home Health Services – Length of Stay
  • New Providers who have submitted at least 50 claims.

 

HOSPICE TOP CLAIM DENIALS & HOW TO AVOID

 

1. Six Month or Less Prognosis Not Supported

This is by far the number one reason for Hospice denials, regardless of the reviewer.  Eligibility requirements being met upon admission is only the beginning.  Throughout the care of the patient there must be continued documentation to support the terminal prognosis of the patient.

2. Medicare Benefit Election Statement Invalid (Statutory/Regulatory Requirements Not Met)

With the changes that occurred to the Election Statement requirements in October 2020, there have been even more denials for the Election Statement being invalid. Hospices must ensure that the requirements for data inclusion on the Election Statement are met and that each one is completed to standards when an admission occurs.  In addition, Hospices must be diligent about the addendum requirements as this is a Condition of Payment.

3. Physician Narrative Statement Missing or Invalid

Some Hospices are still unclear that the certifying physician is 100% required to be the author of the narrative statement to be included in the Certificate of Terminal Illness (CTI).  Having your software system print out a generic certification statement and having the physician sign it with NO clinical content specific to the patient, is a denial waiting to happen.

The CGS Medicare MAC reported that July-September 2022 – 59% of claims reviewed did not support a prognosis of six months or less and that 29% of the claims denied were related to Medicare Benefit Election Statement requirements not being met. These findings are similar for NGS and Palmetto GBA.

HOME HEALTH TOP CLAIM DENIALS & HOW TO AVOID

 

1. Skilled Nursing Services were Not Medically Necessary

One of the best practices in avoiding this denial is routinely performing chart reviews to ensure there is documentation to support a skill was performed at each visit that includes the patient’s response to treatment, progress towards goals and the plan for the next visit and that homebound status is supported throughout the episode.  The plan for the next visit has surfaced as one of the top reasons for denial.

2. Face-to-Face Encounter (F2F) Missing/Incomplete/Untimely

This denial has been in the top three denials since the requirement was implemented in 2011.   Agencies must verify that the F2F encounter visit for the initial certification is incorporated in the patient record and was performed timely, by an allowable practitioner, supports the primary reason for home health services and is signed/dated with a valid signature by the allowed practitioner that conducted the encounter.

3. Initial Certification Missing/Incomplete/Invalid

Agencies should have a process in place to ensure the five required elements of the initial/subsequent certification(s) are met prior to billing the claim.  There must be support that elements are present and signed and dated by the certifying physician.

The CGS Medicare MAC reported that July-September 2022 – 43% of claims reviewed did not support medical necessity for SN/Therapy services provided and that 45% of the claims denied were related to the certification/plan of care requirements not met, including Face-to-Face Encounter denials. These findings are similar for NGS and Palmetto GBA.

Healthcare Provider Solutions has assisted home health and hospice providers nationwide through the medical review process. The HPS Clinical Consulting team can assist with reviewing charts that have been selected for ADR review, prepare appeals for claims denied, provide staff education, and answer any questions you may have. Please let us know if we can help your agency in any way.