Home Health & Hospice Week

If you’re one of the home health and hospice agencies that hoped Medicare would listen to reason and hold off on the resumption of Targeted Probe and Educate review, get ready to be disappointed.

After the Centers for Medicare & Medicaid Services and its HHH Medicare Administrative Contractors announced they would resume TPE Sept. 1, the National Association for Home Care & Hospice reached out to CMS to request a delay, the trade group says. “The continued stressors providers are feeling from the ongoing COVID-19 pandemic and natural disasters” are good reasons justifying a delay, NAHC says in its member newsletter.

The difference: MACs “have been conducting limited medical review since August 2020,” NAHC acknowledges. But “a probe audit such as TPE requires significantly more claims that will be reviewed,” the trade group protests.

CMS doesn’t see the situation that way. “CMS believes that restarting the Targeted Probe and Educate (TPE) program is in the best interest of providers and CMS,” the agency responded to NAHC. “TPE helps educate providers with the goal of reducing future claim denials, and if compliant, future claim audits,” CMS reportedly told the trade group.

In its response, CMS plays down TPE’s impact. “TPE reviews are generally limited to a subset of providers who have billing practices that vary significantly from their peers and are identified as appropriate for reviews through data analysis,” CMS says, according to NAHC. “The TPE program generally involves a small number of claims (generally 20-40) for each round of review. This process is typically repeated for up to three rounds, but MACs discontinue the process if/when providers/suppliers become compliant.”

CMS also repeats the time line flexibility mentioned in the resumption announcements. “CMS has required the contractors to grant prepayment extensions to providers who need more time to comply with the medical record request. If a provider is unable to reply within the required timeframe, they are encouraged to submit an extension request to their MAC,” the agency’s response says.

“NAHC encourages providers to work with their MACs and we have heard some MACs are providing flexibility in the number of ADRs being requested,” the trade group reports.

But TPE resumption is not good news. “This is an additional burden for hospices at a time when the COVID cases are rising, and higher than ever in some areas; as well as when HHAs and hospices are dealing with the pressures of staffing shortages (crisis in some areas) and other pressures such as natural disasters,” NAHC’s Katie Wehri tells AAPC.

The degree to which TPE burdens an agency “will be directly related to the number of ADRs requested and how flexible the MAC will be both in terms of response time extensions and the number of reviews,” NAHC’s Mary Carr tells AAPC. “We have heard that NGS, at least, has provided some flexibility in the number of reviews,” Carr shares.

“Ideally, TPE would be paused,” Wehri notes. “But in the absence of a pause, granting flexibility for a response timeframe is appreciated. It remains to be seen if the MACs will be lenient on that issue,” she says. “The number of records requested under TPE could be extremely burdensome for some providers, so if flexibility regarding sample size were also granted, that would be helpful,” she adds.

How you’ll know: Providers selected for TPE will receive a notification letter from their MAC, CMS and the MACs tell agencies.

Everyone will be starting TPE over at Round 1, even if they were on TPE in more advanced rounds before the hold for the COVID-19 Public Health Emergency began. “All TPE rounds underway prior to the Public Health Emergency are closed,” HHH MAC CGS explains in an updated TPE question-and-answer set. “Selected providers will begin TPE in Round 1 regardless of the round they were in when TPE was paused,” CGS says in the Q&As on its website.

CGS Leads The Pack With 5 Topics

Meanwhile, the HHH MACs are refining their TPE topic lists.

National Government Services is targeting Orthopedic Aftercare (Z47) for HHA claims from March 2020 on in Jurisdiction 6, and General Inpatient Services of more than 7 days for hospices in that region. For Jurisdiction K, NGS lists Home Health Medical Necessity for HHAs and Length of Stay over 730 days for hospices. (HHH MAC J6 includes AK, AZ, CA, HI, ID, MI, MN, NV, NJ, NY, OR, PR, USVI, WI, WA and other territories. JK includes CT, ME, MA, NH, RI, and VT.)

CGS has whittled down its former TPE topic list to Home Health Medical Necessity and New Providers (at least 50 claims submitted) for HHAs. For hospices, it has listed three topics: LOS with Non-Oncologic Diagnosis (LOS 730 days and greater), GIP (7 days and greater), and New Providers (at least 50 claims submitted).

Palmetto GBA so far has kept its target lists at one each for HHAs and hospices — Home Health Services for Eligibility and Medical Necessity and GIP, (7 days or more) respectively.

Note: Find the NGS TPE topics in Sept. 14 Medical Review newsletter at www.ngsmedicare.com/fr/web/ngs/news (scroll down and click on Sept. 14 entry); the CGS topics at www.cgsmedicare.com/hhh/medreview/activitylog.html, and the Palmetto topics at www.palmettogba.com/palmetto/jmhhh.nsf/DIDC/BTPOD0A22I~Medical Review~Targeted Probe and Educate. CGS’ updated TPE Q&As are at www.cgsmedicare.com/hhh/medreview/tpe_faqs.html.