Recently, CMS has replaced the Progressive Corrective Action (PCA) ADR/Medical Review process with Targeted Probe & Educate (TPE). With this change comes a different approach to reviews and how Additional Development Requests (ADRs) are sent to agencies. Much of PCA is still present, but with some key changes, so TPE is not the same old process.
What follows is a comprehensive list of what TPE IS and what TPE IS NOT:
- TPE IS a multiple ADR review of home health agencies. It IS NOT a review of every home health agency.
- TPE IS a 20 to 40 ADR request. It IS NOT the 5 ADR review that the prior Probe & Educate reviews were.
- TPE IS a pre-payment review for the ADRs. It IS NOT a post-payment review, where prior paid claims are re-opened.
- TPE IS conducted by each Medicare Administrative Contractor (MAC). It IS NOT an audit of records by the Zone Program Integrity Contractor/Unified Program Integrity Contractor (ZPIC/UPIC).
- TPE IS conducted by each MAC. It IS NOT and does not affect other ZPIC/UPIC, Recovery Audit Contractor (RAC), or Comprehensive Error Rate Testing (CERT) ADRs, audits, and reviews.
- TPE IS a review that includes a distinct education component after each set of Probe ADRs. It IS NOT a good idea to ignore or not attend this education.
- TPE IS a set of up to three Probes, each of 20-40 ADRs. It IS NOT a Probe, followed by a set of Targeted Medical Reviews (TMR).
- TPE IS a review focused on some home health agencies based on still undefined “edits” for a particular billing, utilization, or perceived risk factor for inaccurate or inappropriate billing. It IS NOT going to target random agencies.
- TPE IS: going to put agencies who receive three sets of Probes at risk for payment suspension, ZPIC/UPIC activity, and extrapolation of findings. It IS NOT going to place agencies at risk for these until a pattern of non-compliance has been demonstrated.
- TPE IS: going to pull the Probe ADRs over a period of time. It IS NOT going to send all 20-40 ADRs at once to an agency.
This list was compiled by QIRT’s Director of Regulatory Reimbursement and Appeals Development, Joe Osentoski, BAS, RN-BC. With 20+ years experience, Joe has completed thousands of ADRs/appeals and hundreds of ALJ hearings dealing with all OMHA offices. Have more questions about TPE? Contact Joe today.
More about Joe Osentoski:
From “How to Handle Your Medicare Hearing” by retired US Administrative Law Judge Robert Soltis; Chapter 39, Recommended Representatives (p.140): “Mr. Osentoski was one of the first non-attorney representatives to appear before me when I was an ALJ, and he stands head and shoulders above every other non-attorney representative. Mr. Osentoski…knows home health law, and prepares thoroughly. His credibility is beyond reproach.” ISBN 978-1-4834-5221-0.