Home Health & Hospice Week

Round timing is provider-specific under new initiative.

Getting a clear picture of the Targeted Probe & Educate program's impact on the home care industry is complicated by "round" confusion.

Old way: Under the Probe & Educate program, the HHH Medicare Administrative Contractors reviewed five claims from every home health agency nationwide in one time period known as round 1.

Agencies that had zero or 1 claim with problems were then done with the program, while HHAs with two or more claims denied were kept on for round 2. The program ended before reaching round 3.

New way: Under TPE, MAC reviewers target specific providers, selecting "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," the Centers for Medicare & Medicaid Services says. TPE reviews 20 to 40 claims per item or service, per round, for a total of up to three rounds. "Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action," CMS says.

Crucial difference: Under P&E, all agencies underwent round 1 in a defined time period. Under TPE, agencies can start on round 1 any time.

A Palmetto GBA spokesperson elaborates further. "The TPE 'rounds' are 'rolling' in nature on a per provider basis and do not have a firm start or stop date," he tells Eli. "While some providers may indeed be entering round 2, others may just be starting round 1. The TPE edits are provider-specific edits that, because they have a staggered implementation, do not lend themselves to analysis by round," he explains.

"There is no monolithic 'round 1' and 'round 2' of all providers, as there was with Probe & Educate," offers Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan.

Instead, HHAs will need to "consider a 'rolling' result of agencies who were selected and completed each round (with completion being defined by each MAC)."

Note: TPE information is on the Palmetto GBA website at www.palmettogba.com/JMB - click "Topics" on the top navigation bar, then "Medical Review," then "Targeted Probe and Educate."