Home Health & Hospice Week

Would your claims fall into these TPE probes on non-cancer diagnosis, LOS, or site of service?

If things look bleak for home health agencies under TPE, it’s even worse for hospices, judging by one HHH Medicare Administrative Contractor’s recently released results.

The TPE results for hospice are the first the industry has seen. That’s because the last time MACs released TPE data, they said there wasn’t enough on hospices to report.

MAC CGS says from Oct. 1, 2017, to Sept. 30, 2018, it completed round 1 review for five hospices under the Targeted Probe and Educate program. Two of those reviews wrapped up in the quarter ending Sept. 30.

CGS reviewers found all five hospices noncompliant, the MAC says in a TPE results article posted Nov. 29, 2018. That means all five had to proceed to round 2 of TPE.

That is worse than home health agencies’ latest TPE non-compliance rate — but not by much. Of 152 HHAs CGS reviewed in the quarter ending Sept. 30, reviewers found only one agency compliant. That means more than 99 percent of HHAs flunked TPE in that time period (see Eli’s HCW, Vol. XXVII, No. 43).

In contrast: MAC Palmetto GBA found about 54 percent of the HHAs it reviewed from October 2017 to September 2018 non-compliant (see Eli’s HCW, Vol. XXVII, No. 45).

Palmetto doesn’t have posted TPE results for hospices. MAC National Government Services hasn’t publicly released any TPE figures.

One Denial Reason Dominates

CGS reviewed two hospices under the probe for Length of Stay with Non-Oncologic Diagnosis (edit 5D000), as well as one hospice each under these three probes:

• LOS greater than 180 Days (edit 5D002),
• LOS >120 Days (edit 5D003), and
• LOS in LTC, NF or SNF (edit 5D004).

The five hospices completing review were located in four states — Delaware, Maryland, Missouri, and West Virginia. The reviews in the most recent quarter were in the first two states, according to the MAC.

All of the review results from the most recent quarter fell into the significant risk category, meaning reviewers determined a 51 percent or higher error rate for claims reviewed, CGS reveals. But for the entire time period since Oct. 1, 2017, 80 percent of the results were in the significant risk category, while 20 percent were in the moderate risk (25 to 50 percent error rate) category.

CGS lists only two denial reasons for the quarter ending Sept. 30: “terminal prognosis not supported” and “MD services not medically necessary.”

Of those top denial reasons, terminal prognosis not supported accounted for an overwhelming 96 percent of the TPE denials, CGS reports.

On its TPE website, the Centers for Medicare & Medicaid Services claims that providers shouldn’t be too worried about the medical review. After all, “providers whose claims are compliant with Medicare policy won’t be chosen for TPE,” CMS maintains. MACs target “providers and suppliers who have high claim error rates or unusual billing practices.”

Even when providers do get chosen for TPE, “the majority that have participated in the TPE process increased the accuracy of their claims,”

CMS insists on its website. The MACs offer one-on-one education for providers.

“However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps,” the agency warns. “These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

With such drastic non-compliance numbers, industry observers worry that legitimate home care and hospice providers may end up with TPE closing their doors.

Use Your PEPPER Report

How likely are you to become a TPE target? You can look at your LOS data for a clue, advises Melissa Abbott with 5 Star Consultants in Camdenton, Missouri.

You can monitor LOS via internal reports you generate, Abbott suggests. Or you can keep track of LOS via the PEPPER report items on the topic: Long LOS (more than 180 days) and Live Discharge with LOS 61-180 days.

Tip: Also pay attention to the dominant denial reason of not supporting the terminal diagnosis, Abbott recommends. “Perform chart reviews to ensure that documentation supports the terminal diagnosis/prognosis/level of care,” Abbott tells Eli.

Smart hospices also will take advantage of free education offered by the MAC, Abbott says.

Option 1: Hospices not yet under TPE should attend MACs’ educational sessions offered via teleconference, webinar, etc., Abbott says.

Option 2: If you already are under TPE, take full advantage of MACs’ one-on-one education, Abbott urges. “Each claim found in error will be discussed and questions answered,” she explains.

Note: CGS’s home health and hospice TPE results are at www.cgsmedicare.com/hhh/pubs/news/2018/1118/cope10075.html. CMS’s TPE webpage is at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.