Eli's Hospice Insider

Providers continue to fail TPE miserably.

The latest numbers for Targeted Probe and Educate are grim for those providers who end up under the medical review program.

Out of 11 completed TPE probes of home health agencies from Jan. 1 to March 31, HHH Medicare Administrative Contractor CGS reviewers found only three compliant — 27 percent. Seven of the probes were for LOS with Non-Oncologic Diagnosis (edit 5D000), while four were for GIP LOC (edit 5D006).

Unsupported terminal prognosis and a missing or invalid physician narrative dominated the denial list at 47 percent and 17 percent, respectively. But invalid Notices of Election did make up 11 percent of denials, too.

Those denial reasons dovetail with the ones found by the Comprehensive Error Rate Testing contractor, MAC Palmetto GBA reports. Common hospice denial reasons under CERT include missing: a completed and signed election of benefits; a physician-signed certification or verbal certification; and face-to-face physician encounter clinical notes.

See more TPE details at https://cgsmedicare.com/hhh/pubs/news/2019/0519/cope12494.html.

Watch out: TPE’s worst outcome isn’t endless medical review — it’s actually going to the next step.

“There are up to three rounds of TPE reviews,” Palmetto says in a question-and-answer set from a recent TPE teleconference. After the three rounds, “then further action is required by CMS. It is not an indefinite process.” 

That action from the Centers for Medicare & Medicaid Services can range from “100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action,” CMS says on its TPE webpage.

Providers do have a chance to get off TPE, Palmetto explains in the Q&A. “What we’re looking for is a claim denial rate or charge denial rate — either one that is greater than 20 percent,” the MAC explains. “If 20 percent or more of your claims are denied, then we are going to progress you. If 20 percent or more of your total charges are denied for the entire sample; then we will progress you to the next round.”

Recent TPE results show very few providers seem able to stay under the 20 percent denial mark.

“It seems like the result of TPE is pre-ordained for most agencies,” laments Joe Osentoski, reimbursement recovery & appeals director with Quality in Real Time in Troy, Michigan.

Part of the reason is just that “so many agencies do not have competent billers to identify ADRs and facilitate responses,” Osentoski tells Eli. That problem also has “significant effects in the Medicare Advantage world,” he warns. CMS has floated an MA carve-in for hospice.

But if you do manage to achieve denial rates under 20 percent, you’ll have new challenges — including extended surveillance. “Once you successfully moved into compliance based upon new thresholds, then you will come off and be monitored through data analysis for the next 12 months,” Palmetto says. The MAC doesn’t specify what exactly it will monitor at what levels.

And you can still get put on TPE for a topic that differs from the initial one. “Just because you were on edit for one service does not mean that you would not be subjected to another,” Palmetto says in the Q&As.