TPE Update: The Only Constant is Change

Yet Another Update to TPE (Targeted Probe and Educate)

THIS JUST IN! (This post updates a blog written and published on 11/8/18)

Medicare Administrative Contractor (MAC) CGS Administrators has just posted its first update to Targeted Probe and Educate (TPE) activity in nearly a year, and immediately updated it. Four more areas to receive additional scrutiny are now added to the prior issues of Home Health Eligibility and Medical Necessary, and Length of Stay (LOS) with the diagnosis of Hypertension.

What’s newly updated?

First updated November 6, 2018:

  1. Added 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 (related to home health claims with length of stay issues)

NOW: on November 9, 2018:

  • A change in edit from providers who submit only 5 visits, to providers who submit claims with 4 to 7 visits in a 60 day episode. These (along with current hospice issues) can be found here.

This addition of stated TPE issues illustrates the constant need to be vigilant for changes to what is being looked at by CMS’ various contractors. Sometimes these changes occur weekly after a long period of inactivity.

What does this TPE update mean?

This revision to records being reviewed addresses:

  • Episodes just under the Low Utilization Payment Adjustment (LUPA) threshold of 5 visits to just over the LUPA threshold of 5 visits.

Looking at episodes where just enough service was provided to receive full episode reimbursement makes sense. Less clear is the MAC’s reasoning to review episodes that are LUPA and just under the threshold. However, the reason for this review may be information gathering on agency practices related to LUPAs. Remember all of this is occurring prior to the significant revision to home health payment from the finalization of the Patient-Driven Groupings Model (PDGM). Since LUPAs in the PDGM 30-day payment period vary based on case-mix grouping, having comparative data for future medical reviews may be behind this change.

No doubt, this change is the beginning of many as we near the start of PDGM.

 

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 JOsentoski@QIRT.com

 

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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