While most agencies will never encounter a Targeted Probe and Educate (TPE) audit under the Centers for Medicare and Medicaid Services (CMS), prudent hospice care providers will understand the purpose and process of the TPE program in order to best prepare should they encounter an audit in the near or long term.
The TPE process typically is used only with those providers that have high denial rates or unusual billing practices. The audit is used as a means to educate providers on how to adhere to CMS’s process and regulations.
“When we say billing, it’s because everything comes to the claim,” Nancy Cary, manager, billing services operations for HEALTHCAREfirst, said in a recent Hospice News podcast. “But it really has to do with the clinical procedures. So, it’s basically a point that Medicare says, ‘OK, we can do some education here.’”
The goal of the program is to identify any errors, correct the problem and help the agency to improve going forward. If chosen, the agency will receive a formal letter from its Medicare Administrative Contractor (MAC). The MAC will review approximately 20 to 40 of their claims and will look for all necessary supporting documentation.
If any of the claims are denied, the hospice agency will then be subject to one-on-one education sessions. The agency is then given a 45-day time period to make adjustments and improvements.
If the agency fails to improve after three rounds of education sessions, the agency could go into a “100% prepay review.” Alternatively, they may face other actions, a recovery audit, suspension of payments, exclusion from Medicare or, on rare occasion, criminal penalties.
Navigating the TPE audit
As long as the hospice completes each required TPE audit, they get a letter explaining exactly what they need to include.
“As long as they’re sending their audits in a timely manner with all supporting medical records for review, it’s not that difficult to navigate,” Cary says. “They do need to know that if it’s denied, they have an additional 45 days to send in an appeal for reconsideration for additional documentation. If the agency is compliant with clinical documentation, face-to face timing, certifications and clinical notes, the audit should go smoothly.”
Larger organizations should be advised that there is potential for a single provider to be in multiple TPE audits based on each National Provider Identifier (NPI). If the agency offers services across multiple care settings, or if the organization has several locations, it could end up with TPEs that overlap.
Common reasons for a TPE audit
When it comes to hospice services, hospice is not treated any differently from how common claim errors are handled. For example, there could be issues with face-to-face requirement timing, including a lack of signature by the certifying physician that appears on the claim. If it’s missing, Medicare may commence an audit.
If CMS notes an ongoing pattern of similar errors, the agency likely will call for TPE for training on the timeliness of a face-to-face, elements of eligibility and recertification. If these elements are not clear in the documentation provided, CMS will likely request additional documents.
“In initial certification, the signature of the certifying physician is probably the number one thing that gets picked up by CMS,” Cary says. “The next item is level-of-care documentation. If they are looking for medical necessity, and if they see a lot of high-level care or general inpatient stays, then they are going to ask questions, dig deeper and look at more documentation.
Best practices: TPE audit
When facing a TPE audit, one of the most important factors is timeliness and responsiveness on the part of the hospice provider.
“Everyone needs to be mindful of the deadlines and respond in a timely manner,” Cary says. “That’s one of the biggest issues; agencies don’t get the paperwork in on time to CMS.”
For those facing an audit, it is helpful to have an internal audit response team in place, Cary says. This team can serve as the main point of contact that gathers the information, ensures it’s reviewed, is submitted and received and verifies that the address and contact information is correct with Medicare.
“They should review everything before sending it out, double checking the accuracy of all the information. It’s important to make sure that even though timeliness is key, agencies aren’t just quickly gathering things and quickly sending them in. It’s a balance between meeting deadlines and accuracy.” Cary says.
This article is sponsored by HEALTHCAREfirst. The experts at HEALTHCAREfirst help providers accelerate reimbursement, maximize cash flow, reduce risk of denials, and go beyond compliance for CAHPS surveys. Click here to connect with us today.
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