Home Health & Hospice Week

Medicare needs to examine its requirements, experts charge.

The latest results from the Targeted Probe and Educate medical review program indicate you are virtually doomed if you land on TPE review.

Why? Out of the 122 home health agencies that HHH Medicare Administrative Contractor CGS reviewed under the TPE round 1 eligibility and medical necessity probe (5A000) from July 1 to Sept. 30, only one was found “compliant,” according to a TPE update posted on the MAC’s website Nov. 29. The other 121 agencies that completed round 1 review for the topic moved on to round 2 of the program.

The results for long-stay and non-response probes were equally dismal, CGS reveals. The MAC completed one probe each for claims with lengths of stay exceeding 120 days (5A002) and 180 days (5A003), respectively. TPE reviewers deemed both agencies reviewed non-compliant, advancing them to round 2.

CGS reviewers completed 28 non-responses to Additional Development Request probes (5A004) in the three-month period, and found all 28 agencies non-compliant, moving them to round 2 as well.

“That failure rate is disheartening,” notes consultant Joe Osentoski with QIRT in Troy, Michigan — not to mention almost “unbelievable.”

“This is very troubling in so many ways,” says Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. “A statistician would find the results invalid, or data was intentionally skewed,” Olson adds.

National Association for Home Care & Hospice President William Dombi finds the extreme numbers “very surprising,” noting they have deteriorated from previous TPE results (see story, p.347).

As in previous TPE periods, the Face-to-Face physician-encounter requirement continues to give HHAs the most trouble, CGS indicates. F2F accounts for about 25 percent of all TPE denials, the MAC says (See story, p. 348, for top denial reasons).

The extreme failure rate under TPE sounds crazy, notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. But it, as well as the denial reasons, are in line with what BKD has seen.

TPE is very intensive, “where there is a large concentration of ADRs — rather than just one off here and there like was typical prior to TPE,” Little explains. That intense level of review “is exposing a number of documentation deficiencies that haven’t previously been escalated to the attention of the providers,” he says.

Silver lining: “On the one hand, it’s good that these issues are being identified so that the providers can have an opportunity to address them,” Little says. “On the other, they are very costly lessons to be learned.”

Past Time For A Change

With physicians responsible for the heavy lifting on F2F documentation, Osentoski wonders if Probe and Educate education from the MACs “is directed to the wrong target?” Perhaps physicians should be the ones receiving MAC education, he tells Eli.

Or an even bigger change is needed. “Given that the alleged noncompliance continues to be documentation-related, it is likely time for CMS to revisit its requirements to make them easier to understand and implement,” Dombi proposes.

“After seven years of repeated difficulties with the face-to-face documentation requirements, it seems the problem is more with the policy rather than the HHAs,” Dombi tells Eli.

Finding only one of 122 agencies compliant “is just nuts,” says Sharon Litwin with 5 Star Consultants in Camdenton, Missouri. “They need to see it’s the process and the auditors, not the agencies,” Litwin agrees.

Note: See the results at www.cgsmedicare.com/hhh/pubs/news/2018/1118/cope10075.html.