Home Health & Hospice Week

One MAC releases new stats about the medical review program.

As Targeted Probe & Educate rolls on, home health agencies are increasingly getting flattened by the new medical review program. So show new TPE results from HHH Medicare Administrative Contractor CGS.

Of the 57 TPE home health probes CGS completed as of June 30, only five resulted in compliant HHAs, the MAC reports in a TPE update posted to its website Sept. 4. That’s a mere 9 percent.

That leaves 52 HHAs — 91 percent — that CGS found non-compliant and that advanced to Round 2 of TPE. That statistic is “pretty staggering,” notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

That compares to a slightly-less-whopping 80 percent non-compliant figure CGS released in its last TPE update, which calculated statistics through March 31 (see Eli’s HCW, Vol. XXVII, No. 20).

In contrast: HHH MAC Palmetto GBA didn’t release figures on how many agencies advanced to round 2, but it did note it denied 30.7 percent of claims it reviewed as of late May (see Eli’s HCW, Vol. XXVII, No. 21). And Palmetto said that 217 of the 2,131 HHAs targeted under TPE had completed round 1 of the program as of May 23. National Government Services hasn’t released TPE stats.

CGS’s completed, Round 1 numbers may not be as high as Palmetto’s, but at least the 57 probes “gives a workable number to draw some conclusions,” notes Joe Osentoski with QIRT in Troy, Michigan.

Both Little and Osentoski report that many more TPE round 1 probes continue in process.

Agencies Head Toward ZPIC/UPIC Scrutiny

The outcome for HHAs that perform poorly is dire, Little points out.

“Providers/suppliers with continued high error rates after three rounds of TPE may be referred to [the Centers for Medicare & Medicaid Services] for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action,” CMS says on its TPE website.

Flunking three rounds of TPE is most likely to result in “a referral to the ZPIC/UPIC, and that will not end well,” Little warns.

Other TEP statistics CGS released include the top five denial reasons (see related box, p. 259), state-by-state denial statistics, and how many agencies are in the “minor,” “moderate,” and “significant” risk categories.

Highlight #1: Washington state saw the highest denial rate with all TPE-reviewed claims fully denied from April 1 to June 30, CGS reports. Utah had the best approval rate.

Highlight #2: Five percent of HHAs under TPE landed in the “minor” risk category, comprising an end-of-round provider error rate of 0 to 25 percent. In contrast, 28 percent were in the “moderate” category of 26 to 50 percent PER and 67 percent were in the “significant” category with a PER of 51 percent or higher, CGS reports.

HHAs that fall into the moderate or significant risk categories receive individual education from CGS, the MAC reminds.

Note: CGS’s TPE update is at www.cgsmedicare.com/hhh/pubs/news/2018/0918/cope8993.html.