Home Health & Hospice Week

GIP is on the TPE radar for hospice claims.

Since Medicare announced the resumption of Targeted Probe and Educate medical review earlier this month, but no specific start date, home health and hospice agencies have been waiting for the other shoe to drop.

Now it has — at least for agencies serviced by HHH Medicare Administrative Contractor Palmetto GBA. “The Targeted Probe and Educate (TPE) process will be resumed effective September 1, 2021,” Palmetto confirmed on its website in an article updated Aug. 31.

How TPE selection will work: “TPE cases that remained open during the Public Health Emergency (PHE) have been closed,” Palmetto explains. Now the MAC is selecting providers for TPE based on “analysis of billing data indicating aberrancies,” error rate results from previous targeted review, or service-specific review error rate results, the MAC notes. “All service-specific reviews will be phased out,” Palmetto adds.

Keep an eye out for TPE notices. “Palmetto GBA will send a notification letter to providers ... that have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information,” Palmetto explains.

Reminder: TPE consists of up to three rounds of review with a 20-to-40 claim sample selected for each round, Palmetto tells providers. In addition to the initial notification letter, “an Additional Document Request (ADR) will be generated for each claim selected,” the MAC says.

Don’t forget, before TPE was halted in the COVID-19 Public Health Emergency, some providers were progressing to a fourth round of TPE review instead of being referred to CMS for further action (see HCW by AAPC, Vol. XXIX, No. 3).

Providers must furnish documentation within 45 days of the date of the ADR. Palmetto will conduct pre-pay reviews and make a payment decision within 30 days from the date the documentation is received and within 60 days of receipt for post-pay review, the MAC notes.

COVID Extensions Available

Don’t get confused by the claim selection process for TPE. When a claim is selected for possible TPE review, it will go into an S B6000 location in Direct Data Entry (DDE). But it’s not actually selected for review until it moves into the S B6001 location, Palmetto explains in an Aug. 27 post on its website.

In other words, “claims initially suspended into location S B6000 may not advance to S B6001 for review and could be released for processing without review,” Palmetto stresses. “Only claims that are selected for review will move from S B6000 to S B6001. Do not send in medical documentation unless the claim suspends to location S B6001, when the ADR will be generated.”

Palmetto’s home health TPE topic is vague, merely listing all HIPPS codes as eligible for review and “review of claims submitted for Home Health Services for Eligibility and Medical Necessity” as the description.

For hospice, on the other hand, TPE is targeting General Inpatient (GIP) care claims. The probe will “review … Inpatient claims for Inpatient Hospice Care greater than or equal to 7 days for Revenue Code 656 and place of service codes Q5004– Q5009,” Palmetto details in its TPE Active Medical Review List.

Then: Initially, the Centers for Medicare & Medicaid Services said it would halt TPE for the duration of the COVID-19 PHE. But that was when a PHE lasting a-year-and-a-half was hard to imagine.

Now: “Medicare contractors do have the discretion to grant an extension to providers who need more time to comply with the medical record request due to hardship,” Palmetto says in the article. “Please be aware that this instruction is specific to restarting TPE and is intended to be temporary in nature; the ability to request an extension will coincide with the COVID 19 Public Health Emergency.”

If agencies “are unable to reply within the required timeframe due to hardship, please submit an extension request outlining your hardship to Palmetto GBA using your preferred submission method,” the MAC instructs. You can address an extension request to “MR TPE ADR Extension Request” and include the identifying claim information (date of service, claim number, beneficiary name/MBI) and the identifying provider information (provider number, provider name and name of requestor) in the request.

Watch out: “Non Response denials count as an error when calculating the probe error rate,” Palmetto cautions. As before, agencies with an error rate above a certain threshold will progress to another round of TPE, and then eventually to CMS for “additional action” if they don’t improve adequately, the MAC recounts.

After each round, Palmetto will contact a provider to offer one-on-one education and issue a result letter that includes the number of claims reviewed, number of claims allowed in full, and number of claims denied in full or in part and associated education, the MAC says. It also will issue an education letter at the conclusion of each reviewed claim, Palmetto adds.

The other HHH MACs, NGS and CGS, have yet to post TPE resumption details on their websites. Non-HHH MACs, however, such as WPS Government Health Administrators and Noridian Healthcare Solutions, have done so.

“CMS has authorized the Medicare Administrative Contractors (MACs) to conduct a 10-claim preview of Round One in addition to the normal TPE process,” Noridian reveals on its website. “This preview is intended to reduce burden for compliant providers, facilities, and suppliers. If the Round one preview results in zero errors, no further action is required and the TPE review will be closed.”

Stay tuned to see whether those same parameters will apply to HHAs and hospices.

Beware: Remember, your early COVID-era claims may be more likely to get you into trouble. “Given all the changes that occurred early in the PHE, claims paid during the first 60 days may be subject to different rules and may be more likely to contain errors, and be ripe for auditing,” warns the Coleman Consulting Group in online analysis.

Note: For more TPE process details, see the link to the Aug. 31 TPE article at https://palmettogba.com/palmetto/jma.nsf/DID/ATZP3S5504. Palmetto’s TPE topic list available via the Aug. 25 link on that webpage.