Home Health & Hospice Week

F2F errors dominate Home Health Probe & Educate results.

Since Medicare officials first announced the Targeted Probe & Educate initiative, home health agencies have been wondering what gets them on - and off - the medical review program.

Up until recently, Medicare Administrative Contractors would say only that vague aberrant billing stats or undefined high claim error rates would land HHAs on TPE (see Eli's HCW, Vol. XXVI, No. 36). On its TPE website, the Centers for Medicare & Medicaid Services said agencies would come off TPE by performing well, meaning demonstrating "low error rates or sufficient improvement in error rates, as determined by CMS."

But now, HHH Medicare Administrative Contractor National Government Services has said in a recent home health-specific TPE webinar that TPE applies when "a high payment error rate above 15 percent" occurs. Agencies must have a PER "of less than 15 percent in order to be released from additional rounds of review" under TPE, the MAC clarified.

Reminder: If you are chosen for TPE inclusion, your MAC will review 20 to 40 claims per item or service, per round, for a total of up to three rounds of review, CMS explains on its TPE website. "After each round, providers are offered individualized education based on the results of their reviews."

MACs will prove one-on-one education after each round, but also may "educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process," CMS says.

The question of which HHAs will receive TPE attention initially remains unclear, however. MACs will "select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. These providers/suppliers and specific items/services are identified by the MAC through data analysis," CMS says.

Difference: CMS has declared TPE its medical review methodology for all of its MACs and provider types now. TPE focuses "on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service," CMS says.

This differs from the initial Home Health Probe & Educate program, which chose claims from every HHA in the nation in its first round. Targeting P&E review from the onset "eliminates burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy," according to CMS.

Timeline: TPE took effect Oct. 1, and targeted providers will receive a letter that will "outline the reason for selection and will provide an overview of the TPE process and contact information," MAC Palmetto GBA explains in a recent TPE article on its website.

Subsequent rounds of TPE will begin 45 to 56 days after individual provider education is completed, Palmetto adds.

Q&A: In a TPE question-and-answer set updated Oct. 25, CMS notes that it doesn't plan to share specific results from the Home Health P&E program. "CMS does not have detailed Home Health P&E data available to the public," the agency notes. But "the most common errors identified during the P&E process were issues related to the Face to Face requirements; including no signature by the certifying physician and encounter notes not supporting all of the elements of eligibility, and recertifications with no estimate of continued need for service or with missing or incomplete or initial certifications."

"These common errors are ones that CMS believes can be effectively addressed through provider education," the agency says.

Note: An NGS TPE presentation for all provider types, similar to the one for HHAs, is at www.ngsmedicare.com/ngs/wcm/connect/813d9f1cb243-4295-a7e0-0826c26892f4/1928_0917+Targeted+Probe+and+Educate+TPE-09+28+2017_rev_508.pdf?MOD=AJPERES. A link to the Q&A set is on CMS's TPE webpage at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.