Home Health & Hospice Week

CMS should rethink bringing back this medical review program, industry reps urge.

What’s the last thing home health and hospice agencies need while facing a COVID-19 surge, staffing shortages, vaccination hesitancy, value-based purchasing, more intense surveys, and more? If you said Targeted Probe and Educate medical review, you’re in good company.

Recap: The Centers for Medicare & Medicaid Services paused the TPE program when COVID-19 hit in March 2020, saying it would stay paused for the duration of the COVID Public Health Emergency. But on Aug. 12, CMS announced it would resume TPE. CMS did not provide any specifics, including a start date, however. Then Palmetto GBA was the first HHH Medicare Administrative Contractor to confirm that it would be restarting TPE and added a Sept. 1 effective date (see HCW by AAPC, Vol. XXX, No. 31).

Now HHH MAC CGS has joined Palmetto in announcing TPE’s resumption. CGS also confirmed a Sept. 1 start date, even though its announcement posted to its website on Sept. 2. “Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment” for TPE review, the MAC said.

CGS referred providers to its “Home Health and Hospice Medical Review Activity Log” webpage “for a list of review topics.” Although that page still lists the TPE topics as “paused,” presumably they are the ones CGS will pursue (see box, this page).

HHH MAC National Government Services mentioned in its Sept. 6 newsletter for Part A providers that CMS is resuming TPE. “Providers/suppliers who are included in the TPE process will receive a notification letter from their MAC,” NGS notes in the newsletter.

But NGS hasn’t updated any of its other TPE pages or issued new information, as of press time. The MAC did list one home health and one hospice TPE topic, however (see box, this page).

CGS’s announcement does acknowledge the potential for providers to undergo more than three rounds of TPE. “If the denial rate remains high after three rounds, CGS will refer the provider to CMS for additional action, which may include: additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation,” the MAC says. “The review may be discontinued if appropriate improvement and an error rate of < 25 percent is achieved during the review process.”

Now that TPE’s resumption is clear, one industry trade group is taking CMS to task for the move.

“It is not clear why CMS chose now, when the pandemic is worsening, to resume TPE,” the National Association for Home Care & Hospice blasts in its member newsletter. “Providers continue to feel pressure from COVID-19 related stressors, such as inadequate staff with increasing high-acuity patient referrals,” NAHC says.

“TPE places significant burden on providers during ordinary times, let alone during times when COVID-19 surges and natural disasters are occurring concurrently (e.g. hurricanes and wildfires),” NAHC continues. “Many home health and hospice providers simply do not have the resources during this time to adequately comply with a TPE process that requires 20 to 40 additional documentation requests,” the trade group maintains.

“Therefore, NAHC is urging CMS to reconsider resuming TPE and suspend TPE until the PHE has ended,” it says.

Alternative: “If suspension of TPE until the end of the PHE is not possible, CMS should instruct the MACs to not subject providers to TPE if responding to medical review requests will create an undue burden due to the PHE and/or responding to natural disasters,” NAHC exhorts.

Palmetto did outline such a process in its TPE announcement on Aug. 31. “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 said. That discretion will end with the COVID-19 PHE, Palmetto indicated.

Note: The CGS announcement is at www.cgsmedicare.com/hhh/pubs/news/2021/09/cope23220.html and the NGS announcement is at www.ngsmedicare.com/ca/search-details?selectedArticleId=3287370.