The Consistency of TPE Failure Rates

Home health agencies undergoing TPE reviews continue to fail at impressive rates for the same reasons as previous reviews. Let’s talk about the consistency of TPE failure rates and how they link to RCD, PDGM, and more.

Einstein Was Right

Many people credit Albert Einstein with exclaiming “The definition of insanity is doing the same thing over and over again, but expecting different results.” While there may not be proof that he actually said that, there is ample proof that the sentiment is correct.

Medicare Administrative Contractor (MAC) CGS Administrators has just posted an update to its Targeted Probe and Educate (TPE) activities in home health and hospice. This update covers probes completed January 1, 2019 to March 31, 2019. And the biggest takeaway is unfortunate consistency. In other words: home health agencies undergoing TPE reviews continue to fail at an impressive rate, and for the same reasons as previous reviews.

The Findings

For home health agencies undergoing a Medical Necessity review that did respond to the probe request, the findings are:

Eligibility and Medical Necessity edit 5A000 (Round 1) Probes completed July 1, 2018 -September 30, 2018 Probes completed October 1, 2018 -December 31, 2018 Probes completed January 1, 2019 -March 31, 2019
Probes Completed 122 55 81
Providers Compliant After Round 1 Completion 1 2 2
Providers Non-Compliant after Round 1 Completion (Advancing to Round 2) 121 53 79
Providers with Non-Responses to ADRs for Round 1 23 14 19
Eligibility and Medical Necessity edit 5B000 (Round 2) Probes completed July 1, 2018 -September 30, 2018 Probes completed October 1, 2018 – December 31, 2018 Probes completed January 1, 2019 – March 31, 2019
Probes Completed NA 3 10
Providers Compliant After Round 2 Completion NA 0 2
Providers Non-Compliant after Round 2 Completion (Advancing to Round 3) NA 3 8
Providers with Non-Responses to ADRs for Round 2 NA 14 1

The TPE Round 1 compliance has remained low at 0.8% in 3Q 2018, then 3.6% in 4Q 2018, and now 2.5% in 1Q 2019. The number of agencies that do not respond at all to the TPE probes remains abysmally high as well.

A Little Good News

The tiniest good news is that two of the ten agencies completing TPE Round 2 were found compliant. However, there are few valid excuses for non-responses at any level of review. Additionally, the 80% continued non-compliance was after the education portion of TPE was provided to the agency and time was allowed to improve. If this is not proof of insanity, it’s very close to it.

Top Denial Reasons

Top Denial Reasons remained consistent with the CGS results over the past three quarters:

Top Denial Reasons Probes completed July 1, 2018 -September 30, 2018 Probes completed October 1, 2018 – December 31, 2018 Probes completed January 1, 2019 – March 31, 2019
Face-to-face missing/incomplete/untimely 25% 27% 30%
Initial certification invalid 13% 12% 14%
Documentation did not support the medical necessity of therapy services NA 8% 7%

The PDGM, RCD, TPE Connection

As the Patient-Driven Groupings Model (PDGM) looms in 2020, and the Review-Choice Demonstration (RCD) is about to restart in Illinois on June 1 with four more states to follow (OH, NC, FL, TX), the need for basic medical record compliance is still evident. Home health agencies struggling to maintain compliance with physician face-to-face encounter requirements, certification requirements, and therapy assessment, reassessment, and skilled service requirements will have an even tougher time with PDGM and RCD.

While these results from CGS Administrators only reflect “targeted” agencies, most agency reviews produce the same commonly identified issues. A rigorous self-evaluation of agency procedures, policies, and processes is a standard PDGM preparation recommendation. Indeed, agencies must also consider the need for staff education on what constitutes a reimbursable record and compliant documentation. Reconsider if your agency’s Quality Assurance Performance Improvement (QAPI) program is addressing key indicators of compliance. Do not ignore Quality Assurance (QA) and record reviews in the sweep of other pending changes. Outsource if needed, but don’t ignore its importance.

Whether it genuinely was Einstein’s quote or not, home health needs to break the pattern of doing the same (wrong, non-compliant) things over and over again and expecting a different result. Creating a new, compliant model is imperative for keeping agency doors open in the PDGM/RCD home health world.

Outsource with QIRT

QIRT will help your agency manage reviews, appeals, PDGM processes, and more, leaving you free to focus on what’s most important: your patients. ContactUs@QIRT.com

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