Cirque de Home Health: Juggling Payment Risks – TPE update

THIS JUST IN – TPE UPDATE! Medicare Administrative Contractor (MAC) CGS Administrators has just posted its first update to Targeted Probe and Educate (TPE) activity in nearly a year. Four more areas will receive further scrutiny. These TPE updates are in addition to Home Health Eligibility & Medical Necessary and Length of Stay (LOS) with the diagnosis of Hypertension.

Updated November 6, 2018, are:

  1. Agencies who fail to respond to ADRs
  2. Home health claims for providers who submit only 5 visits in a 60-day episode
  3. Greater than 120 days (related to home health claims with length-of-stay issues)
  4. Greater than 180 days (also related to home health claims with length-of-stay issues)

Find these along with current hospice issues at CGS Medicare 

These TPE additional issues illustrate the constant need to be vigilance. Agencies must watch for changes to what CMS’ various contractors are reviewing.

The finalization of the Patient-Driven Groupings Model (PDGM) completes the three-ring circus of home health change (added to Conditions of Participation – CoPs and Review-Choice Demonstration – RCD) …or does it?

While PDGM will have a sweeping effect on most agencies, keep your focus. Losing sight of current CMS Medical Review (MR) activity poses a current and ongoing threat to agency operations.

What is TPE?

Fully implemented in late 2017, Targeted Probe and Educate (TPE) is the only way that CMS’ Medicare Administrative Contractors (MACs) issue Additional Development Requests (ADRs) for medical review. Each round of the TPE, called a probe, can result in 20-40 ADRs being issued, evaluated, and subsequent actions determined by the results. With allowable error rates ranging from 15% (National Government Services) to 20% (Palmetto GBA) to 25% (CGS Administrators), getting additional rounds of probes and up to 80 ADRs are a strong possibility. This is significant and can be easily overlooked as agencies consider how to implement the current CoPs and future PDGM changes.

Recent TPE Results

While overall TPE results data from the MACshas been scarce, both Palmetto GBA and CGA Administrators have shared some information on how agencies have initially fared under TPE. CGS Administrators’ data is found at CGS Medicare.

Let’s look at probes that were only looking at issues of eligibility and medical necessity. Only 4 of the 45 probes issued to providers for the period October 2017 through June 30, 2018, met the allowable error rate. Even worse (yes – worse is possible): only 1 of 12 probes issued to agencies that failed to respond to the prior Probe and Educate reviews met the allowable error rate. And finally, from a later sample base of agencies checked for eligibility and medical necessity (period April 2018 to June 2018) did not show improvement: 29 of 30 probes went to round 2.

This demonstrates the continued danger of agencies being distracted by PDGM and not giving ongoing compliance issues their due attention. Note the only “silver lining” from RCD (for the states Illinois, Ohio, Florida, Texas, and North Carolina): when RCD is implemented, TPE activity in that state is to be suspended. However, Zone Program Integrity Contractor (ZPIC), Unified Program Activity Contractors (UPIC), Recovery Audit Contractor (RAC), and Comprehensive Error Rate Testing (CERT) activities are not affected and will continue.

A QIRT Expert’s Take on the TPE Update

Reviewing the data provided by CGS Administrators, it seems as though TPE is discovering the same issues that the both Progressive Corrective Action (PCA) and Probe & Educate found earlier. The number of providers that continue to be denied due to Non-Responses to ADRs is really unacceptable at this point. Each agency is informed the TPE Probe will occur, and ADR submission is not a new process. Home health agencies must learn how to respond to ADRs properly and timely or find a competent consultant to complete the response. Doing neither just hands money back to the Medicare Administrative Contractor, both now and with future probes.

After record submission, the denial reasons are fairly consistent with prior findings. The most prominent reasons are face-to-face encounter and therapy medical necessity. Note that invalid face-to-face encounters and certification denials may mask medical necessity denials.

Conclusions and Recommendations for Agencies:

  1. Respond to the TPE update probe: internally or with consultant help
  2. Review all technical/administrative areas of the record prior to the final billing of a record. Include face-to-face encounter content and certification requirements.
  3. Use the CGS Administrators website for in-service material with staff regarding top denial reasons. Palmetto GBA and NGS also have top denial reasons with suggestions on correcting them. While often just restatements of the applicable regulation, reasons do shed some light on record requirements. In-service staff on these topics. Even if not in MAC Jurisdiction 15, the website offers up the most detailed link of regulatory requirements.
  4. If your agency receives a TPE letter:
    1. Read it all
    2. Organize the response or
    3. Obtain outside assistance to manage it and obtain the best result possible.
  5. Once in TPE, always seek out and accept the MAC-offered education.

Full PDGM is a year away. RCD will not hit every state. But TPE is here now.

The dreaded “billing aberrancies” trigger TPE and pose an administrative and financial cost to home health agencies. If TPE is not managed correctly, it may significantly impair cash flow when an ADR occurs. Cash flow will decrease in cases where claims must be appealed (currently more than three years to get an administrative law judge hearing). When juggling CMS’ payment and medical review requirements, do not drop the ball on Targeted Probe and Educate.

By Joe Osentoski, BAS, RN-BC, QIRT Reimbursement Recovery and Appeals Director

Want to learn more about TPEs and all things compliance? Have questions about upcoming RCD? Reach out to Joe and his team today: call 1.855.485.QIRT or email


QIRT: The tools and expertise you’ve been searching for.

QIRT leads the home health and hospice industry in coding, billing, and consulting. Serving agencies across the United States, QIRT provides outsource coding and OASIS, quality assurance, ADR and appeals services, outsourced billing, consulting, and education. With Quality Cycle Management (QCM) and the unique QIRT Advantage Platform, QIRT monitors home care and hospice agency processes and checkpoints for end-to-end solutions to compliance and success.

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