Home Health & Hospice Week

Expert: Crucial data missing from TPE report.

One HHH Medicare Administrative Contractor's TPE results report provides some valuable data that will help agencies navigate TPE medical review.

For example: For the first time, MAC CGS gives its cut-off for the "minor" risk category that will allow providers to get off Targeted Probe & Educate review - a 25 percent "error rate." Agencies in the "moderate" 26-50 percent error rate category and the "significant" 51-100 percent error rate category will stay on TPE, the article indicates. It also says how many agencies from TPE's first six months are in each category - 20 percent minor, 33 percent moderate, and 47 percent significant.

These categories are somewhat different than the original P&E program, where errors on zero to one claims (up to 20 percent) allowed providers to get off review.

However: A direct comparison isn't necessarily available. It appears that the risk categories for TPE are based on the "Provider Error Rate," according to Centers for Medicare & Medicaid Services materials about the program.

The PER is "the percentage of the total amount of money billed in that group of TPE ADRs that was denied," explains consultant Joe Osentoski with QIRT in Troy, Michigan. It's essentially the same as the Charge Denial Rate, Osentoski tells Eli.

"It's the amount of money denied that is key to getting off the review," Osentoski stresses. "That shows the true trend of provider compliance or noncompliance."

In contrast, "many claims can partially deny for issues, so I have always found that as a lesser indicator of review outcome," Osentoski says.

However, while CGS furnishes the percentage of agencies that were found "complaint" and "non-compliant" under TPE round 1, a state-by-state bar graph of denials, the percentage of agencies in each risk category, the percentage of reasons for denials, and the error rate category definitions, it does not provide PER or CDR statistics, Osentoski emphasizes.

"The percentage of claims with denials ... may affect the number of appeals to be filed, [but] it does not have a direct effect on whether review activity continues or the other actions are initiated," Osentoski points out.

Keep in mind: A direct comparison is probably not going to be available even between MACs conducting TPE either, Osentoski expects.

"Each MAC has a different Charge Denial Rate percentage that will get the agency another round of reviews," he relates. "So even when comparing the percentage of agencies proceeding to Round 2 of a TPE, or percentage of claims denied in any state, or what it means have a Minor, Moderate, or Significant risk - these all vary from MAC to MAC and I do not believe will afford much meaningful comparative data."