Home Health & Hospice Week

Some Targeted Probe and Educate practices have finally been put into print, thanks to a new Medicare transmittal.

For example: The Centers for Medicare & Medicaid Services originally said after three rounds of TPE review, providers that hadn’t improved up to the required level would be referred to CMS for “further action.” That action could range from “100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

But some providers had been placed on a fourth round of TPE. One such case was acknowledged by HHH Medicare Administrative Contractor National Government Services last October (see Eli’s HCW, Vol. XXIX, No. 3).

Now CMS has updated its Medicare Program Integrity Manual to reflect that practice.“For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation,” CMS says in May 15 Transmittal No.10132.

“If CMS directs the MAC to conduct an additional round of TPE review, the MAC shall send the provider/supplier a notification letter indicating that an additional round of review is required,” CMS continues in Change Request 11695.“These reviews shall be of claims with dates of service at least 45 days after the prior round’s post probe education and after the provider/supplier has received the aforementioned notification letter.”

CR 11695 is at www.cms.gov/index.php/files/document/r10132pi.pdf.