The Centers for Medicare & Medicaid Services (CMS) recently launched its home health Targeted Probe and Educate (TPE) program, which aims to improve your claims accuracy. But what does the TPE process really look like, and what can you expect from the experience?
The TPE post-payment program involves 20 to 40 records per round, with a possibility of up to three rounds of review, explains Cheryl Adams in her educational session “Protecting Revenue by Preventing Denials in CMS’ Newest Targeted Probe and Educate Reviews.” That’s some significant scrutiny!
Unusual Billing Practices Are a Red Flag
If all your claims are compliant, you’re off the hook. You likely won’t have to go through the TPE process, according to the CMS TPE webpage.
But: If you have high claim error rates, unusual billing practices, or bill for items and services with high national error rates, you should expect your Medicare Administrative Contractor (MAC) to come knocking.
MAC Denial? Then Back to the Classroom
If your home health agency is chosen for the TPE program, you’ll receive a letter from your MAC, CMS explains. The MAC will then review 20 to 40 of your claims and their supporting medical records. If the MAC determines that your claims are compliant, you won’t face another TPE review for at least one year on the selected topic.
But if the MAC denies some of your claims based on the review, you will need to attend a one-on-one education session, CMS states. Then, your MAC will give you at least 45 days to make changes and improve your claims. You may need to undergo up to three rounds of education sessions, until your claims become compliant.
Next steps: But what if, after all three rounds, your claims accuracy doesn’t adequately improve? CMS says that this shouldn’t be a concern for most providers, but if this happens your MAC will refer your agency to CMS for additional action. You may face a 100-percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.
Beware of 4 Common Claim Errors
Typically, your MAC will select the specific topics for review based on its data analysis, according to Novitas Solutions’ TPE question-and-answer page. If you visit your MAC’s website, you’ll find helpful resources like documentation checklists for TPE topics. Novitas offers these checklists for each claim area under TPE review.
Watch out: CMS points to the following claim errors as being the most common among home healthcare providers:
- Missing signature of the certifying physician;
- Documentation doesn’t meet medical necessity;
- Encounter notes don’t support all elements of eligibility; and
- Missing or incomplete initial certifications or recertification.
MACs like CGS are selecting providers for TPE based on several factors. Your MAC may select your agency for the TPE process if its analysis of your billing data indicates “aberrancies that may suggest questionable billing practices,” CGS notes in its TPE process tutorial. Or your MAC may select providers based on a targeted review’s error rate results or on service-specific review error rate results.
MACs Focused on These 3 Mistakes
Recent MAC reviews have revealed that most claims denials under the TPE process relate to certification requirements, CMS says.
In particular, MACs are finding:
- Issues related to the Face-to-Face requirements, including no signature by the certifying physician and encounter notes that don’t support all of the eligibility elements;
- Recertification with no estimate of continued need for service and recertification denials because the initial certification was missing, incomplete, or invalid; and
- Claims denied for 56900, no response to the additional documentation request (ADR).
Bottom line: When facing the TPE process, your home health agency must arm itself with full knowledge of the Face-to-Face requirements, affirmation definitions, and certification and recertification statements, Adams stresses. If you can conquer these important elements and ensure complete, thorough required documentation, you can avoid denials and risking lost revenue.
