The U.S. Centers for Medicare & Medicaid Services (CMS) will resume Targeted Probe and Educate audits (TPE) in September. The agency had temporarily suspended TPE activity to ease the burden on hospices and other providers during the COVID-19 public health emergency.
The TPE program is designed to identify providers that have frequent errors on their Medicare claims or billing practices that CMS considers to be unusual. TPEs, typically conducted by Medicare Administrative Contractors (MACs), also focus on services that have high national error rates and represent a financial risk to Medicare, according to CMS.
A TPE is designed to be more of an educational process than punitive.
“CMS’ Targeted Probe and Educate program emphasizes improving rather than penalizing and is a sensible approach,” a spokesperson for LeadingAge, the association of nonprofit providers of aging services, told Hospice News. “Accurate billing is helpful to both CMS and to providers and fosters good stewardship of resources.”
Audits can be a very time-consuming and expensive process for providers, particularly in terms of personnel work hours.
When selected for a TPE, hospices receive a notification letter from their MAC. The contractor then pulls and examines between 20 and 40 of the organization’s claims and supporting medical documentation.
If the MAC finds discrepancies, the hospice has 45 days to correct the issue. If no problems are found, the MAC would not perform a similar audit on the same organization for one year. If the MAC denies claims as a result of this review, the provider is invited to one in-person education session.
Common issues that could result in an audit or claims denial include missing signatures for certifying physicians, documentation that is otherwise incomplete or inaccurate or that does not support the medical necessity of a service. For hospices, MACs also consider high rates of live discharges as a red flag.
The audits will resume September 1.
Hospice utilization among Medicare decedents rose to exceed 50% for the first time during 2018, according to CMS. As utilization climbs, so does the amount of dollars CMS spends on hospice care, spurring the agency to step up enforcement in an effort to control costs. Medicare hospice expenditures rise by about $1 billion annually.
Many hospice providers express uncertainty about their ability to weather an audit. Even prior to the pandemic, fewer than 50% of hospices indicated that they were ready for a federal audit or additional document request, according to a 2019 survey of 170 organizations by Optima Health.
Some providers in the hospice community are concerned that CMS is jumping the gun on resuming these audits given the current national spikes in COVID-19 cases.
“In our discussions with providers, they report that they are overwhelmed with the surge in COVID-19 patients and are also facing unprecedented staffing shortages, especially for nurses,” said Judi Lund-Person, vice president for regulatory and compliance for the National Hospice and Palliative Care Organization (NHPCO). “Many comment that they do not know how they will manage the staff resources to care for patients and respond to a TPE audit in the midst of this very serious COVID spike and staffing shortages.”
Health care providers have seen staff turnover rise during the pandemic, and hospice is no exception. Slightly more than 20% of health care workers have considered leaving the field due to stress brought on by the pandemic, and 30% have considered reducing their hours, according to a recent study published in JAMA Network Open.
But the shortage did not begin with the outbreak, it has been building for years as hospice employees age with the rest of the population and seek retirement. About 10,000 people in the United States reach the retirement age of 65 every day, according to the Kaiser Family Foundation.
“The [National Association for Home Care & Hospice (NAHC)] is concerned that TPE is resuming at the same time that providers are experiencing a significant uptick in COVID cases (the reason that TPE was paused) with the existing, and now worsening, staff shortages,” a NAHC spokesperson told Hospice News.
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