Eli's Hospice Insider

Are you going to be one of the 'targets' in Targeted Probe & Educate medical review?

It's been more than three months since the Medicare program kicked off its transition to Targeted Probe & Educate for medical review for all provider types, including hospices. If you aren't quick to pick up the new methodology's ins and outs, TPE could seriously slow your cash flow and even close your doors.

To avoid claims denials and prevent being put through even more rounds of TPE, hospices must understand how to identify and respond to Additional Development Requests generated under the program - as well as shore up documentation in high-risk areas.

Read on for information the three Home Health & Hospice Medicare Administrative Contractors have revealed which may help you survive and thrive under TPE:

All your ADRs are now under TPE. The Centers for Medicare & Medicaid Services instructed all of its MACs, not just the hospice ones, to switch their entire medical review operations over to TPE in October (see Eli's Hospice Insider, Vol. 10, No. 11). That means "as of 10/01/17 all ADRs are for the Targeted Probe and Educate Process and we are not sending any other Palmetto GBA Medical Review ADRs at this time," Palmetto says in a recent question-and-answer set about the process. "We're only focused on TPE." National Government Services' entire PCA medical review process moved over to TPE for "all lines of business," it emphasizes in the slides for a webinar about the program.

Watch for the initial letter. Before receiving ADRs under TPE, the MAC will send you an initial letter telling you you're subject to the program, MAC CGS notes on its TPE website. "The letter will outline the reason for selection, and will provide an overview of the TPE process and contact information," CGS says.

If you are getting ADRs but didn't receive a letter, it's probably because your mailing address isn't what you think it is. "To ensure you receive this very important information (initial notification letter and ADR letters), this is a good time to make sure your address information is correct with provider enrollment," Palmetto urges in its Q&A.

"The letters are based on PTAN and the provider address registered with Provider Enrollment," Palmetto elaborates. "Each provider sets their organization's provider enrollment information separately for their address choice."

Heads up, chains: "If the address on file is the individual practice, the letter will go there," Palmetto says. "If it's listed as the corporate headquarters, it will go there."

You're not off the hook yet. If you haven't received a TPE letter and corresponding ADRs yet, you're not out of the woods. NGS's medical review department "is starting to stagger notification letters related to TPE," the MAC told its Provider Education Advisory Group, according to minutes posted from its November meeting. "Staggering the letters means we are not sending out all letters to all agencies at once. This allows MR the opportunity to process claims in a timely fashion."

Palmetto says the same in its Q&As. "Much like every other organization, we try to stage to make sure that we're not over-burdening providers and receiving too much documentation all at one time," the MAC explains. "Providers are notified of our medical review strategy focus so there will be ample time if you prepare for any audit that may come your way."

Many agencies haven't seen TPE letters yet, notes attorney Robert Markette Jr. with Hall Render in Indianapolis. Home care and hospice providers may be paying more attention to reviews from Program Integrity Contractor AdvanceMed, "because they are more aggressive and tend to extrapolate, which leads to massive appeal efforts," Markette tells Eli.

However: Providers that stay on TPE due to sustaining high levels of denials - 15 percent or more according to NGS - will eventually get referred to PI contractors and face the same fate, the MACs warn.

Also, it looks as though providers in some disaster-relief areas are seeing themselves put back in the TPE rotation, reports clinical consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. One of Warmack's clients in Texas received a TPE letter from Palmetto, she relates. "Palmetto halted ADR activity back in August when the hurricanes hit. Now that that is behind us and the holidays are over, it makes sense that Palmetto would return to their contracted responsibilities as well."

Bad timing: "It is not an ideal time for my clients, because everyone is so very busy trying to get all the new Conditions of Participation regulations implemented," Warmack laments. "But we ... are extremely resilient and will rise to the challenge."

Target selection. The MACs are still close-mouthed about how they are selecting hospices for TPE. However, CGS did announce its initial hospice topics back in October (see Eli's HCW, Vol. 11, No. 11), and now the MAC has posted its new TPE topics for hospices too (see box, p. 9). And all the MACs agree that "data analytics" are the tool they are using. In other words, if your billing stats stick out like a sore thumb in an area the MAC or CMS considers high-risk, you'll be getting a TPE letter.

Sample size depends. CMS and its MACs have explained that under each round of TPE, the MAC will request 20 to 40 claims to review. "We take many things into account when deciding what sample size to use," Palmetto says. That includes "the type of service and overall protection of the Medicare Trust Fund."

And "part of what's included would be your billing practice or billing volume. If you are a small provider submitting 15 claims a month, Palmetto GBA is not going to require 40 claims from you as that would be burdensome to your organization," the MAC assures providers.

End date varies. As with start dates, providers' end dates for TPE rounds will vary. The MAC will decide how many claims your agency must furnish. Then, "we do not have a timeline to stop the ADRs; we will keep going until we reach between 20 or 40 depending on which level is set for that particular provider," Palmetto says.

Keep in mind: "When we refer to a round, it's not like we're starting today and all providers we put in at the end of the day we expect to be done by this other date," Palmetto explains in a separate Q&A. "Each provider is going to be treated independently. The first draw of claims to be reviewed that is pulled from them is round one. The rounds are specific to the provider not specific to the program."