The Centers for Medicare and Medicaid Services (CMS) has certainly kept the home health industry on its toes, with 2017 being a banner year for regulations and proposals. Between the now on-hold home health groupings model (HHGM), and the new conditions of participation (CoPs) set to take effect on January 13, 2018, home health providers have been hit with a lot of changes.

In keeping with this trend, in early October, CMS expanded its Targeted Probe and Educate (TPE) program, which is a documentation review process to weed out improper payments, nationwide to include all Medicare Administrative Contractors (MACs), which are are companies contracted with CMS to perform audits. In its pilot stages, which began in June 2016, the program only affected select states, including Florida.

The program involves a combination of an audit of claim samples conducted by MACs and an education component to ultimately reduce errors in the claims submission process and prevent improper payments, according to CMS.

The nationwide expansion of the program is just another hit for the home health industry at large, according to Diane Link, director of clinical services at Pennsylvania-based BlackTree Healthcare Consulting.

“The timing of this couldn’t be worse. We’re struggling to get our policies and processes in place for the revised CoPs,” Link told Home Health Care News. “To be hit with this on top of [CoPs] at this timing is enough to send any executive director crying. It’s overwhelming.”

Greater scrutiny

Unlike previous auditing, TPE audits are triggered when an agency either has a high rate of claims being denied, often based on incidences like invalid face-to-face encounters or if therapy utilization is higher than deemed reasonable, according to Joe Osentoski, reimbursement recovery and appeals director at New York-based Quality in Real Time (QIRT).

Specifically, MACs will only analyze agencies that have the highest claim error rates or follow billing practices that differ significantly from their peers, according to CMS.

The TPE review and education process includes an audit of 20 to 40 claims followed by “one-on-one, provider-specific, education” to address any errors within the provider’s reviewed claims.

Agencies have a 45-day grace period to remediate their errors, according to Link. If an agency is found to be compliant, they will not be audited under the TPE program for another year.

On the flip side, if high error rates continue in their claims, agencies are subject to a second round of probe-and-educate. If errors persist, agencies face a third round of scrutiny.

“After the third round, if they’re still having issues, then [MACs will] escalate it up to CMS for possible further action,” Link said.

Further action could involve a Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC) audit, or even a 100% pre-pay review, according to Osentoski. ZPICs are subcontracted by Medicare to perform retrospective audits that can come with severe risks for providers, including payment suspension.

In addition, an agency’s ability to participate in Medicare or Medicaid can be impacted under TPE, Link explained.

The good and the bad

Compliant agencies with low denial rates should have no trouble with the rollout of the TPE program, according to Link.

Struggling agencies that are subjected to rounds of probe-and-educate, on the other hand, will face both operational and financial burdens, Link and Osentoski explained.

“The biggest impact is when you get selected, you have a significant possible financial impact on your agency,” Osentoski said. “Because you are already targeted, there is almost a presumption that there might be some inappropriate billing going on.”

On the operational front, Link added, “It also is very time-consuming for an agency to pull together 40 claims … and get it out the door and reviewed. It totally interrupts workflow.”

For some providers, the TPE program offers an opportunity to identify key areas in their claims submission processes, according to Dawn Futris, risk management and infection control manager at Illinois-based NorthShore University HealthSystem Home Health and Hospice.

“Targeted probe and educate allows the opportunity to know where the problem is, know you are on [the MACs’] list, and the agency can either take the steps to correct the issues or suffer the consequences,” Futris told HHCN.

For Cheryl Meyer, director of clinical excellence at Chicago-based Advocate Health Care’s Advocate at Home, preparation is key.

“From a preparation standpoint, we are reviewing our procedures we already have in place to respond to ADRs and Comprehensive Error Rate Testing [audits],” she said.

Link advises other providers to follow suit.

“Agencies really need to be proactive before they submit a claim to make sure that clinical review has been done to ensure that they are compliant with the requirements,” she said. “I think now is the time for agencies to be proactive and educate staff and do those audits internally to make sure that you’re in compliance so that when you do get hit with [ADRs] you can pass in the first round.”

Written by Carlo Calma