Originally published December 10, 2018. Copyright 2018, Eli Research. Reproduced with permission from Eli's Hone Care Week. For subscription information, call (800) 874-9180.
The latest results from the Targeted Probe and Educate medical review program indicate you are virtually doomed if you land on TPE review.
Why? Out of the 122 home health agencies that HHH Medicare Administrative Contractor CGS reviewed under the TPE round 1 eligibility and med- ical necessity probe (5A000) from July 1 to Sept. 30, only one was found “compliant,” according to a TPE update posted on the MAC’s website Nov. 29. The other 121 agencies that completed round 1 review for the topic moved on to round 2 of the program.
The results for long-stay and non-response probes were equally dismal, CGS reveals. The MAC completed one probe each for claims with lengths of stay exceeding 120 days (5A002) and 180 days (5A003), respectively. TPE reviewers deemed both agencies reviewed non-compliant, advancing them to round 2.
CGS reviewers completed 28 non-responses to Additional Development Request probes (5A004) in the three-month period, and found all 28 agencies non-compliant, moving them to round 2 as well.
“That failure rate is disheartening,” notes consultant Joe Osentoski with QIRT in Troy, Michigan — not to mention almost “unbelievable.”
“This is very troubling in so many ways,” says Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. “A statistician would find the results invalid, or data was intentionally skewed,” Olson adds.
National Association for Home Care & Hospice President William Dombi finds the extreme numbers “very surprising,” noting they have deteriorated from previous TPE results (see story, p. 347).
As in previous TPE periods, the Face-to- Face physician-encounter requirement continues to give HHAs the most trouble, CGS indicates. F2F accounts for about 25 percent of all TPE denials, the MAC says (See story, p. 348, for top denial reasons).
The extreme failure rate under TPE sounds crazy, notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. But it, as well as the denial reasons, are in line with what BKD has seen.
TPE is very intensive, “where there is a large concentration of ADRs — rather than just one off here and there like was typical prior to TPE,” Little explains. That intense level of review “is exposing a number of documentation deficiencies that haven’t previously been escalated to the attention of the providers,” he says.
Silver lining: “On the one hand, it’s good that these issues are being identified so that the providers can have an opportunity to address them,” Little says. “On the other, they are very costly lessons to be learned.”