There are decades-old home health providers that have not yet gone through the Medicare Targeted Probe and Educate (TPE) process. But all home health leaders should familiarize themselves with the review process and its potential outcomes, as well as its challenges.
That’s one key takeaway from a recent Home Health Care News webinar that was sponsored and presented by MatrixCare.
Broadly, TPE is a medical review program that began for the home health and hospice settings in December 2017. The goal of the program is to weed out improper payments by zeroing-in on providers with high claims denial rates or unusual billing practices.
The program was put on hold in March 2020, in accordance with the public health emergency. It was then reestablished in September 2021.
TPE has three pillars. Target refers to errors or mistakes that are identified through data in comparison to providers or peers.
Probe is the examination of 20 to 40 claims. The claim size is meant to be large enough to get a clear picture of the behavior without intending to be burdensome, Rachael Feeback, senior product manager at MatrixCare, noted during the presentation.
Education means helping providers reduce claim denials and appeals through one-on-one individualized education.
Some common claim errors include things like a missing signature of the certifying physician, documentation not meeting medical necessity and missing or incomplete certifications or recertification documents.
When a provider becomes the subject of a TPE audit, they receive a letter explaining the process. Then a Medicare Administrative Contractor (MAC) reviews between 20 to 40 of their claims and supporting medical records. If the audit finds discrepancies, after education occurs, the provider has 45 days to fix these issues. After this, the process begins again.
“If you fail three rounds, you could be referred to the OIG or CMS, you could even be facing a UPIC or a SMRC audit,” Feeback said. “It’s really important that you have a good process here.”
FaithHospice — a end-of-life care services provider based in Byron Center, Michigan — was the subject of a TPE audit last year.
Currently, FaithHospice is in the middle of the second round.
The TPE process has been an “all hands on deck” effort for the organization.
“We had 25 charts targeted, so that’s on the lower end of the range,” Michelle Baas, clinical informatics coordinator at FaithHospice, said during the presentation. “I couldn’t imagine if we had to pull 40. Our administrative assistants that work in the office have had to print a lot of documents. Our quality team is reviewing and writing a summary letter for each case to summarize that. Our quality manager reviews each and every chart, and puts it all in the correct order, because they have a specific way that they want the documents received.”
Additionally, FaithHospice’s billing team helps with submission and uploading. The team also monitors the site to see if the company has been approved or denied.
The company’s executive director and medical director have both been involved in the process.
After the audit, FaithHospice’s entire clinical management team has had to be involved in educating the staff.
“It has really changed the way they’re focusing on their documentation,” Bass said.
