As a response to the COVID-19 emergency, the U.S. Centers for Medicare & Medicaid Services (CMS) pressed pause on the targeted probe and educate (TPE) program in March 2020. A year later, CMS has plans to resume the program, according to an August 2021 MLNConnects newsletter.
Broadly, TPE is a medical review program that began for the home health and hospice settings in December 2017. The purpose of the program is to weed out improper payments by focusing on providers with high claims denial rates or unusual billing practices.
If providers are selected for a TPE audit, a Medicare Administrative Contractor (MAC) reviews between 20 to 40 of their claims and supporting medical records.
“They’re going to be looking for things that may indicate if the provider has claims that are possibly representing errant billing to CMS because you can’t substantiate the need for the service,” Cindy Campbell, director of operational consulting at WellSky, told Home Health Care News.
If the review shows discrepancies, the provider has 45 days to correct the issues.
On the flip side, the MAC will not audit the provider again for a year if no problems come up. If the MAC denies claims as a result of this review, the provider will receive a one-on-one education session to help reduce errors in the claims submission process.
With the TPE program, CMS aims to be educational rather than punitive.
Despite CMS indicating the resumption of TPE, there has been uncertainty surrounding its exact return date.
“[CMS] announced this back in August, but there was confusion around when exactly,” Campbell said. “Also, there is pushback to this resumption of the TPE program.”
Indeed, the National Association for Home Care & Hospice (NAHC) recently urged CMS to suspend TPE until the end of the public health emergency.
While the exact resumption date for TPE remains unknown, providers should begin preparing now, according to Campbell.
“Be sure within your own billing department, or in working with an outsourced billing company, that you’re checking the ADRs and that this is done on a ritual basis,” she said. “That is one practical tip, and then understanding how to respond per that individual MAC’s requirement. Make sure you know what your payer’s requirements are for responding to a probe.”
In the coming days and weeks, it will also be important to ensure that home health and hospice staff have the knowledge to utilize “defensive documentation” techniques.
“How do we show medical necessity and skilled need,” Campbell said. “What does that mean? It’s about really teaching our staff how to document defensively and in a really concise manner. It’s more than just documenting. It’s understanding from a clinical practice perspective.”
Looking ahead, Campbell believes that it’s important for providers to continue to advocate for themselves at this time.
“This is a very hectic time,” she said. “I’ve been on the phone with providers all week and in the last few weeks. They are feeling the heat, again, of the public health emergency. The impact is so high.”
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