Eli's Hospice Insider

Use this expert advice to head off, or defend against, TPE probes.

The Targeted Probe and Educate medical review program has not been kind to 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.

In contrast: MAC Palmetto GBA found about 54 percent of the HHAs it reviewed from October 2017 to September 2018 non-compliant. Palmetto has not have posted its TPE results for hospices. MAC National Government Services hasn’t publicly released any TPE figures.

CGS ran the TPE probes based on diagnosis, length of stay, and site of service.

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 www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.