Home Health & Hospice Week

Widespread Review Choice Demo may become a TPE alternative.

Medicare is dipping its toe into the medical review waters for COVID-era claims with its resumption of post-payment review for claims from all dates. But the date it will reinstate the much more aggressive Targeted Probe & Educate medical review program is still unclear.

Recap: The Centers for Medicare & Medicaid Services began TPE medical review in late 2017, and the initial rounds had crushing denial rates in the 90s (see HCW by AAPC, Vol. XXVII, No. 32). CMS initially said providers would undergo up to three rounds of TPE, then get referred to CMS for “further action.” That action could range from “100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action,” CMS indicated on its TPE webpage.

However, in late 2019 and early 2020, providers reported starting a fourth round of TPE in some cases. Then in May 2020, CMS updated its Medicare Program Integrity Manual to reflect that practice. “For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred 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,” CMS said in May 15, 2020 Transmittal No. 10132.

Pandemic: When COVID-19 hit, CMS said in a Frequently Asked Question set issued in March 2020 that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic” (see Eli’s HCW, Vol. XXIX, No. 12-13). Then CMS quietly restarted regular medical review in August 2020 — but not TPE (see Eli’s HCW, Vol. XXIX, No. 27). And now CMS has announced its restarting post-pay review (see story, p. 162).

The good news is that without TPE, “it looks like the volume of claims subject to this post-payment review will be relatively small per agency,” observes Joe Osentoski with Gateway Home Health Coding & Consulting. “The volume of post-payment reviews that have been received on pre-PHE claims has been small,” Osentoski recalls.

“Not to minimize the risks and pitfalls of any medical review, but this just extends the universe of claims subject to review,” he adds. However, that will come with waiver-related risks, industry veterans note.

Dodging a bullet: In addition to announcing a resumption of post-payment review, CMS confirms in a June 9 message that “the Targeted Probe and Educate program (intensive education to assess provider compliance through up to 3 rounds of review) will restart later.”

What “later” means is “impossible to predict,” judges M. Aaron Little with BKD in Springfield, Missouri.

“CMS has given zero direction on that,” Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tennessee points out about a TPE resumption timeline.