Update: Medicare Targeted Probe & Educate

the new CMS Targeted Probe & Educate (TPE) initiative that started on October 1.

  • The Targeted Probe & Educate (TPE) is for ALL types of Medicare providers. It is modeled after demonstration projects with home health agencies and hospitals.
  • Both home health providers and hospice providers may be the subject of a TPE. Theoretically, an agency that has both a home health provider number and a hospice provider number could get a TPE for each provider number. It is uncertain at this time if NGS will coordinate their efforts to avoid this.
  • Unlike the Home Health Probe and Educate (HHPE), in which ALL home health providers had at least one round of 5 claims reviewed, the TPE will focus on certain providers based on data analytics.
  • The TPE will involve a review of 20-40 claims, for up to 3 rounds of reviews. NGS told us today that home health agencies will have 20 claims reviewed in Round 1.
    • How will the providers be selected? NGS will analyze data for the following categories:
    • Billing comparisons to peers
    • Trends in medical reviews
    • Utilization patterns
    • Results of Round 2 of the HHPE (Successful appeals will not make a difference.)
  • HHPE Round 2 results are just one of the components above, so don’t assume that if your agency was not in Round 2 of HHPE, or did OK in Round 2, that you will avoid TPE.
  • The areas for review will be determined by NGS based on data analysis, an improper payment reduction strategy and CMS guidance.
  • CMS has set the compliance target at a 15% Payment Error Rate (PRE). This is important!
    • An agency’s compliance is not based on the Claims Error Rate (eg. 20 claims reviewed/3 denied = 15%) Your claims error rate is irrelevant.
    • The Payment Error Rate is based on the % of dollars denied among your 20 claims. (eg. $60,000 in total claims/$30,000 in full or partially denied claims = 50% payment error rate.)
    • Under the scenario in the bullet above, $9,000 in denied claims would be a 15% PRE.
  • Providers will receive education after each round of review. Providers that are not compliant will receive Round 2 of 20-40 ADRs after education is complete. Same with Round 3.
  • NGS is beginning to send out Notification Letters to home health agencies in Jurisdiction K on a staggered basis. The letter will inform your agency that it will have a TPE audit, to anticipate 20, and what to expect from the process.

NGS has a good education program explaining the Targeted Probe and Educate process for home health providers, and a similar one for hospice providers. Some of you may have already participated. If not, below are upcoming dates. Register on the NGS website. I strongly recommend that you and your teams participate in one of these webinars.

• November 16, 2:00 – 3:00pm, Home Health TPE
• November 28, 2:00 – 3:00pm, Hospice TPE
• December 7, 10:00 – 11:00am, Hospice TPE
• December 11, 2:00 – 3:00pm, Hospice TPE