Home Health & Hospice Week

A second MAC reveals some of its TPE targets.

While providers are still figuring out the Targeted Probe & Educate medical review program, some details are becoming clear.

HHH Medicare Administrative Contractor CGS has issued the specific topics it's currently using to select providers for TPE review. Following are the MAC's current hospice TPE areas (for HHA topics, see Eli's HCW, Vol. XXVI, No. 2):

• LOS with Non-Oncologic Diagnosis: selects hospice providers that submit claims with length of stay greater than 730 days and non-oncologic diagnosis code.

CMS has expressed concern about long-stay non-cancer patients for a long time, notes attorney

Robert Markette Jr. with Hall Render in Indianapolis. "Providers should anticipate that having patients on hospice for more than two years will almost certainly lead to greater scrutiny," Markette advises. The combo of a long stay and non-cancer diagnosis will result in a red flag.

"Of course, LOS alone does not disqualify a patient," Markette points out. "But a hospice provider must be prepared to explain why the patient continues to be hospice-eligible with a two-year LOS." And keep in mind that "the MAC (or any other auditor) will be extremely skeptical of a patient's eligibility in that case."

Take action: "Providers need to be aware of their LOS for patients - averages and outliers," Markette urges. "With data mining, the CMS/MAC/ZPIC/etc. can easily target these outlier claims," he warns.

LOS in LTC, NF or SNF: selects hospice providers that submit claims with HCPC codes Q5003 (Hospice care provided in nursing long term care facility [LTC] or non-skilled nursing facility [NF]) and Q5004 (Hospice care provided in skilled nursing facility [SNF]), for any non-oncologic diagnosis code and a length of stay greater than 180 days.

This has been another area of concern for CMS for years, and a special focus point for the HHS Office of Inspector General, Markette points out. Hospice patients in facilities "tend to stay on service much longer," Markette notes. "OIG has been pretty clear in its belief that this is inappropriate and the result of pressure from the facility, an effort by the provider to curry favor from the facility, or something similar." If your facility patients are staying on service more than 180 days, or if their stays are even just longer than those for your patients outside the facility, "that will raise a red flag," Markette warns.

Take action: Hospices that "provide care in facilities must be extremely proactive in regards to the types of patients, diagnoses, etc.," Markette recommends.

GIP LOS: selects hospice providers that submit claims with revenue code 0656 greater than or equal to seven days.

This is another OIG favorite target. In a 2016 report, the OIG denied one-third of the GIP claims it reviewed (see Eli's HCW, Vol. XXV, No. 14). The year before that, a Florida hospice self-reported GIP billing mistakes and agreed to pay $10.1 million to resolve the alleged overbilling problem (see Eli's HCW, Vol. XXIV, No. 23).

No response to ADR: selects providers that fail to respond to ADRs. CGS is targeting both home health and hospice providers with high rates of nonresponse. And a representative for Palmetto GBA tells Eli the MAC is focusing reviews on this topic as well.

Other Palmetto topics: The Palmetto spokesperson says in addition to ADR nonresponses, the MAC will focus on "eligibility and medical necessity" and "errors identified during round one and/or two of the Probe and Educate reviews." Those topics mirror the ones already published by CGS for home health agencies. Palmetto will also publish services under TPE review on its website in the future, the rep says.