Clinical Compliance

The Anatomy of Targeted Probe and Educate (TPE): What You Need to Know Now

10/03/2022

Where does your agency stand with Targeted Probe and Educate (TPE)?

I am aware of several agencies that are entering the third round of TPE. That is not where you want to be!

What is Targeted Probe and Educate (TPE)?

CMS’ Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.

Medicare Administrative Contractors (MACs) are under contract with the Centers for Medicare and Medicaid Services (CMS) to assess compliance with regulatory requirements. Three MACs cover different regions of the United States: CGS Administrators, Palmetto GBA, and National Government Services (otherwise known as NGS, which services most of New England).

MACs use data analysis to identify providers and suppliers who have high claim error rates or unusual billing practices. MACs also identify items and services that have high national error rates and are a financial risk to Medicare.

This algorithm illustrates the process:

MACs will focus on providers who have the highest claim denial rates or who have billing practices that vary significantly from their peers. If agencies fail the third round of TPE, they will be referred to CMS for possible extension of TPE or perhaps further action as warranted.

MACs have established what they feel are acceptable “denial rates.” For National Government Services (NGS), that number is currently 15%. It is NOT 15% of the claims, but rather the total dollar amount of the claims submitted. Agencies should strive for a number less than 15%.

What Can You Do to Reduce Denials?

One of the top reasons for denials is an agency’s failure to respond to the original Additional Development Request (ADR) in a timely manner.  It is critical to pay attention to dates. Agencies have 45 days to respond to an ADR once it has been received. Each ADR includes a list of documents that must be submitted. Only submit what is required. Sending more documents than what were requested could be considered a violation of HIPAA.

How Can Your Agency Receive Proper Payment and Avoid Further Scrutiny? 

Follow these tips for your agency’s successful response to ADRs:

• Submit documents in an orderly fashion (whether through paper or NGS Connex).
• Include everything that is requested.
• Review Face-to-Face documentation for accuracy and completeness.
• Confirm that physician orders are signed AND dated.
• Submit attestation statements for handwritten signatures.
• Be sure that documentation supports homebound status and skill. Utilizing a cover letter can help enforce these critical points.
• Look at Low Utilization Payment Adjustments (LUPAs)! Agencies are seeing an increase in denials when there are only a few visits in the second or subsequent 30-day periods.
• Promote stronger case management. Clinical managers should consider case conferences at the time of admission. Another critical time point is when patients are approaching the end of their first 30-day period.
• Encourage staff to communicate with each other when there is a change in visit frequency (for example, when therapy discharges a case and nursing stays active).
• Make sure that all staff are knowledgeable about the two criteria for homebound status, and what constitutes skill.

MACs have 30 - 60 days to review submitted documentation and make a decision on the claim.

TPE’s Focus on Education

Take advantage of the education offered by TPE reviewers. Agencies will have 45 days to provide education to staff prior to entering the next round of TPE. Maximize this time to educate your staff and conduct internal audits.

TPE Updates on the CMS Website

CMS’ website site was updated on September 16. It includes valuable information as well as an informational YouTube video on TPE. Check it out here:

https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe

Minimize your agency’s risk of governmental reviews by adhering to home health eligibility basics. Corcoran Consulting Group’s seasoned consultants can help your agency review care plans, patient charts, and prepare specific recommendations.  Contact MA@corcoranconsultants.com for a no-obligation conversation.