Home Health & Hospice Week

Do you know the difference between your charge error rate and your claim error rate?

Whether you want to avoid Targeted Probe & Educate review or get off TPE once you get put on, consider this expert advice:

• Know your risk. Use tools such as CGS’s Comparative Billing Reports to see where you stand in relation to your peers. Instructions for downloading your CBR, which covers stats such as total claims billed, average reimbursement per claim, and denial rates, are at www.cgsmedicare.com/hhh/education/materials/pdf/mycgs_comparative_billing_reports_hhh.pdf.
• Respond. When you do receive a TPE documentation request, respond — urges Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan. You can do so internally or with help from an outside consultant.
• Review. Check all technical denial areas prior to final billing of a record, Osentoski advises. That includes face-to-face encounter content, certification requirements, and physician estimate requirements.
• Educate. Use TPE feedback, particularly on the top denial reasons, and MAC educational materials to prep your staff on the TPE target areas.
• Learn more. Educate yourself about the TPE program. For example: The amount of money denied (Provider Error Rate) is still not reflected in CGS’s released statistics, Osentoski points out. “Know that this is different than the Review Decisions by State and is the key number that determines the Risk Category for future action,” he says.

Tip: CGS says it uses PER to make TEP determinations. But Palmetto GBA says in a June TPE question-and-answer document that “for escalation from one round to the next, we’re looking at both claim denial rate and charge denial rate,” which is the same as your PER.

Note: See Palmetto’s TPE Q&A at www.palmettogba.com — click on “Jurisdiction M Home Health and Hospice MAC” in the right-side menu; select “Medical Review” from the pull-down “Topics” menu in the top bar; click on “Targeted Probe & Educate”; then choose the Q&A document posted June 27.