Home Health & Hospice Week

Plus: Don’t hit this key in DDE, MAC warns.

If you haven’t received a letter informing you that you are on Targeted Probe & Educate medical review, that doesn’t mean you’re off the hook for the Home Health TPE campaign.

Palmetto GBA and CGS are “currently analysing data and identifying providers who will be placed on Targeted Probe and Educate (TPE) review,” says a spokesperson for the HHH Medicare Administrative Contractors.

When going from the first to second round of Probe & Educate, CGS saw about 5 percent of agencies exempted from the second round due to having 1 or 0 claims denied under round 1, and Palmetto saw about 15 percent exempted, the MACs told Eli earlier this year.

“Currently we do not have the exact percentage of providers who will be placed on TPE,” the representative says. But Palmetto and CGS expect to see lower ratios of home health agencies subject to the program. That’s because the MACs “have seen an overall decrease in the number of claim errors and agencies have improved their performance in round two” of P&E, according to the rep.

Details are still fuzzy on what exact metrics the MACs will use to select providers and claims for review under TPE. But “providers demonstrating billing practices that vary significantly from their peers will … be placed on TPE,” the source says.

Also: “Providers that are already on targeted review with high claim error rates will be transitioned to TPE,” the MAC rep adds.

If you do get selected for TPE, it’s paramount to respond to ADRs on time, urges National Government Services in an article posted Oct. 3. (See advice for dealing with ADR non-responses in Eli’s HCW, Vol. XXVI, No. 35.)

Tip: In the FISS/DDE system, the ADR letter follows Page 06 of the claim, NGS advises. “The online ADR letter consists of two pages; to view the second page, press the <P8>/<PF8> key to move forward to the next page.”

But “be sure to not press the <P9>/<PF9> key while viewing a claim in the SB6001 status,” NGS warns. “This will cause the claim to recycle and generate a second ADR letter.”

The MAC will make review determinations within 30 calendar days of receiving the provider’s requested documentation, NGS adds in the article. Under TPE, the MAC will furnish providerspecific education after each round. “In addition, there is an opportunity for intra-round education as well if the nurse reviewer identifies a common theme that can be easily corrected during the review phase,” NGS explains in an earlier article about TPE.

Important: “The educational sessions are not an appeals forum nor do the result letters and/or the educational sessions extend the appeal period,” NGS says.

CMS has directed all MACs to replace “all current MAC medical record reviews” with three rounds of TPE, NGS says. While TPE usually will be pre-pay, it could also be post-pay, NGS adds.