Home Health & Hospice Week

Face-to-face continues to be a killer.

Round 3 of the Targeted Probe and Educate medical review program is underway, and that could mean drastic consequences soon. However, new TPE stats show that agencies’ performance is improving over time.

For the quarter ended Dec.31, 2019, HHH Medicare Administrative Contractor CGS found 23 percent of the home health agencies it probed under TPE compliant, the MAC says in new statistics posted to its website Feb.26.That means 77 percent of providers flunked TPE review and the MAC moved them onto the next review level.

However: Compliance rates vary greatly between rounds.CGS found only 13 percent of HHAs compliant in its Round 1 probes in the quarter. In contrast, the MAC found 42 percent of HHAs compliant after Round 2, and 50 percent of HHAs after Round 3.

Round 3 data is still very limited, with CGS recording only two completed Round 3 probes in the quarter.MAC National Government Services recently confirmed it has completed at least one Round 3 probe as well (see Eli’s HCW, Vol. XXIX, No. 3).

“The improvement in compliance between probe Round 1 to probe Round 2 is not where it should be, but still also a net positive,” observes Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

Those results may seem dire, but they actually are a little better than in previous time periods. For the year-ago quarter, CGS reported 97 percent of HHAs failing TPE (see Eli’s HCW, Vol. XXVIII, No. 6).

When compared to other MACs, CGS’s data does seem more severe. For the latest period for which it released data, the quarter ending Oct.2, 2019, MAC Palmetto GBA reported finding 45 percent of HHAs compliant — and thus flunking 65 percent of agencies.

Those PGBA stats are for Rounds 1 and 2, since the MAC hadn’t reported any Round 3 results yet.NGS hasn’t publicly reported its TPE statistics.

Face-To-Face Problems Hard To Beat

The vast majority of TPE probes CGS has completed are for the topic of “eligibility and medical necessity,” with the MAC completing 595 probes in that area. In comparison, CGS completed 98 TPE probes for nonresponse to an ADR, 12 probes for low visit utilization, one probe for Length of Stay exceeding 120 days, and one probe for LOS exceeding 180 days.

Face-to-face physician encounter problems rank first as denial reasons at 28 percent.

“The majority of issues with non-com­pliance are coming from face-to-face encounter content,” Osentoski points out.“Even with education provided by CGS between probes, it may not be as much an issue of the agency not knowing what to do, but getting it done” — in other words, securing “a valid timely physician face-to-face encounter.”

FTF dominates “the majority of my consul­tative time,” Osentoski notes.“Nearly nine years after implementing face-to-face as a home health requirement, it is still the bane of home health compliance.”

Problems with initial certification (14 percent), medical necessity for therapy visits (8 percent), and missing or invalid recertification estimates (6 percent) are next on CGS’ list.

Good news: Thanks to the Trump adminis­tration’s regulatory relief initiative, Medicare no longer requires the physician recert estimate as of Jan.1.

Note: The CGS TPE stats are at www.cgsmedicare.com/hhh/pubs/news/2020/02/cope16111.html. To see Palmetto’s latest stats, go to www.palmettogba.com, click on “J11 MAC Home Health and Hospice” in the right-hand column, select “Medical Review” under the “Topics” tab in the top bar, click on “Targeted Probe and Educate,” and scroll down to and click on the Oct. 24 article.