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Since October 2017, Targeted Probe and Educate (TPE) has been implemented by Medicare Administrative Contractors (MACs) nationwide for home care and hospice. The three MACs carry out TPE, review charts, and calculate denial percentages.

Denial percentages hold agencies accountable by sending them to the next level of review if they exceed the allowed denial percentage.

Maximum Acceptable Denial Percentages per MAC:

 

Is Your Hospice at Risk of Being Subjected to TPE?

There are a variety of reasons that could lead to a hospice being subjected to a Targeted Probe & Educate review. In their review of hospices since February 2019, PGBA announced that they identified 400 hospices that they will review under TPE—specifically for non-cancer diagnoses with long lengths of stay.

Since October 2017, NGS and CGS have targeted a significant number of hospices with denials in excess of the acceptable percentages. As a result, we now have more insight into the top denial reasons for hospice.

If you suspect that your hospice might be subjected to TPE, you should begin a thorough review of all charts. If your claims are targeted, it’s crucial to ensure that you are prepared for the extensive level of review conducted by TPE.

 

 Let’s take a closer look at the top 5 denial reasons and how to avoid them: 

 

  1. Provided Information Doesn’t Support a Terminal Prognosis of 6 Months or Less

According to Medicare Hospice requirements, the information provided does not support a terminal prognosis of 6 months or less.

Tips to Avoid this Denial

Keep in mind that this denial is specific to the documentation regarding the patient’s terminal prognosis, not the patient’s terminal diagnosis—an important difference.

It’s critical to document for the inevitable overall outcome of the patient’s terminal state, not for a specific diagnosis. Documentation upon admission and throughout care of the patient should clearly support that the patient remains with a terminal prognosis of 6 months or less. 

 

  1. Invalid Election Statement—Unmet Statutory/Regulatory Requirements

The election statement is invalid because it doesn’t meet statutory/regulatory requirements.

Tips to Avoid this Denial

Hospices must ensure that the election statement contains all of the specific criteria that Medicare requires.

Key elements that may contribute to this denial: 

      • Identification of the hospice the patient is admitted to is missing on the election statement
      • The effective date of the election does not line up with other dates
      • Signatures are not dated
      • Signatures are not provided by appropriate legal representatives
      • The patient wasn’t given the opportunity to name an attending physician from the community

 

  1. Physician Narrative Statement Was Not Valid or Was Not Present

The physical narrative statement was either invalid because it was incorrectly completed or was not present in the Certificate of Terminal Illness (CTI).

Tips to Avoid this Denial

The physician narrative included in the CTI must be created by the physician and be a true clinical narrative specific to the patient. Other staff cannot create the narrative and boxed/canned statements cannot be applied in the clinical narrative portion.

The CTI must be new at the beginning of each benefit period and must be updated with the current clinical findings as a result of assessments, including the face-to-face encounter, once applicable.

 

  1. Face-to-Face Encounter Requirements Aren’t Met

The required face-to-face encounter (F2F) is insufficient because it doesn’t meet CMS’ documentation criteria.

Tips to Avoid this Denial

The face-to-face encounter (F2F) is required for each and every benefit period beginning with the 3rd benefit period of the patient. It’s important to understand that this should be the 3rd or later benefit period across all time that the patient has been in hospice care.

The F2F can be conducted by a non-physician practitioner (NPP), but the NPP cannot certify the patient for hospice. Consequently, the NPP is required to communicate the clinical findings from the F2F to the certifying physician. Those findings will be used to compose the clinical narrative for the CTI.

The F2F must be signed and dated by the physician or NPP that conducted the visit. The encounter must occur prior to the patient’s certification for the current benefit period. 

 

  1. Documentation Indicates that the General Inpatient Level of Care Wasn’t Reasonable or Necessary

According to Medicare Hospice requirements, the documentation indicates the General Inpatient (GIP) level of care was not reasonable and necessary. Therefore, the payment will be adjusted to the routine home care rate.

Tips to Avoid this Denial

The GIP level of care requires patients to have a symptom that is uncontrolled and that cannot be controlled in any other setting other than an inpatient unit. The majority of denials that HPS has dealt with in this category have not been full denials of GIP or even denials that the patient met GIP requirements when being admitted to GIP. The reoccurring issue observed is that patients are being billed under the GIP level of care after the symptom is under control. Once the patient is no longer suffering from uncontrolled symptoms, the patient should be billed under the appropriate level of care.

As long as hospices are carefully documenting the details of each patient’s clinical situation and each patient meets the eligibility requirements for hospice care—these denials are avoidable. Don’t be the hospice that gets technical denials for careless mistakes, like incorrect format of the election statement or completing CTIs with boxed/canned statements that are not specific to the patient.

HPS is ready and willing to assist agencies in compliance chart reviews in an attempt to avoid 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.

Learn More About TPE Support

HPS would also like to invite you to our two-day hospice workshop in Nashville, TN on June 25-26, 2019.  These two days will be full of compliance education and reimbursement regulatory updates.