Home Health & Hospice Week

Successful TPE rounds are followed by 12 months of monitoring, MAC reveals.

The Targeted Probe and Educate medical review program has been hammering home care and hospice providers that fall into its crosshairs. But TPE’s worst outcome isn’t endless medical review — it’s actually going to the next step.

Reminder: “There are up to three rounds of TPE reviews,” HHH Medicare Administrative Contractor Palmetto GBA says in a question-and-answer set from a recent TPE teleconference. After the three rounds, “then further action is required by CMS. It is not an indefinite process.”

That action from the Centers for Medicare & Medicaid Services can range from “100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action,” CMS says on its TPE webpage.

Providers do have a chance to get off TPE, Palmetto explains in the Q&A. “What we’re looking for is a claim denial rate or charge denial rate — either one that is greater than 20 percent,” the MAC explains. “If 20 percent or more of your claims are denied, then we are going to progress you. If 20 percent or more of your total charges are denied for the entire sample; then we will progress you to the next round.”

Recent TPE results show very few providers seem able to stay under the 20 percent denial mark — CGS most recently reported a 97.4 percent failure rate for round 1 (see Eli’s HCW, Vol. XXVIII, No. 6). “It seems like the result of TPE is pre-ordained for most agencies,” laments Joe Osentoski, reimbursement recovery & appeals director with Quality in Real Time in Troy, Michigan.

Part of the reason is just that “so many agencies do not have competent billers to identify ADRs and facilitate responses,” Osentoski tells Eli. That problem also has “significant effects in the Medicare Advantage world,” he warns.

But if you do manage to achieve denial rates under 20 percent, you’ll have new challenges — including extended surveillance. “Once you successfully moved into compliance based upon new thresholds, then you will come off and be monitored through data analysis for the next 12 months,” Palmetto says. The MAC doesn’t specify what exactly it will monitor at what levels.

And you can still get put on TPE for a topic that differs from the initial one. “Just because you were on edit for one service does not mean that you would not be subjected to another,” Palmetto says in the Q&As.