Finding Your Way Through and out of the Medicare Target, Probe & Educate Initiative

Posted on Monday, November 25, 2019 2:10 PM

Finding Your Way Through and out of the Medicare Target, Probe & Educate Initiative

By Kimberly Searcy Gunter, RN, BSN, CDI-P, HCS-O, HCS-D

By now, if you’re in home health and hospice, you’ve heard of – or been part of – the Target Probe and Educate (TPE) initiative put in place in 2017 by the Centers for Medicaid and Medicare Services (CMS) to help reduce denials and appeals, decrease provider burden, and improve the medical review and education process. Medicare Administrative Contractors (MACs) are targeting those agencies with high denials or claims that are unusual compared to peers, in other words the outliers.  What is interesting is that each MAC has been given discretion to choose their own focus, whether claims will meet coverage, what error rate is to be considered compliant, and when the supplier/provider “target” should be removed from the TPE. So, each MAC has set their own denial percentage as follows: NGS – 15%, Palmetto GBA – 20%, and CGS – 25%, which means your agency must fall below the specified percentage of denials during the probe and educate process. For example, if your agency is in NGS’ territory and has 40 claims pulled, then no more than six can have a denial or your agency will continue to the next round of TPE.

When you do receive a denial, it’s imperative to appeal immediately to have the inappropriate determination of non-coverage reversed.  While the total percentage of denials will be considered to determine if an agency will move to the next round, determination reversals can be considered and may keep you out of a follow-up round of TPE. Once an agency has gone through, and failed, three rounds of TPE, the MAC could refer the agency to CMS for further action that may result in a full prepayment review, extrapolation of denial determination for up to six years of data, and/or revocation of Medicare billing services.

The most important thing you can do for your agency is to be proactive! Before submitting claims, have your team (or outsourced agency) perform a pre-billing clinical documentation review. Once you know your pre-billing trends, implement an auditing program that identifies and addresses risk areas. Review each round of results trends released by your MAC and assess your compliance within each specific area.   Focus on compliance related to documentation and coding. Perform pre-bill audits on 100% of Medicare charts for a time-period to ensure each will support medical necessity, F2F, and technical requirements. If unsure of the requirements, refer to the Medicare Program Integrity Manual.

Each MAC has released TPE round data with not only the top five denial reasons but CGS also has a full, current list of denial reasons. The below list is hyperlinked to the respective MAC data so you can find more in-depth information as well as tools and resources to assist you with compliance.

Home Health Denial Reasons:

CGS: (most stringent in all three rounds performed to date)

1. F2F encounter missing, incomplete, or untimely
2. Initial certification missing, incomplete, or invalid so entire recert episode denied.
3. Medical necessity submitted did not support reasonable and necessary care of a skilled therapist.
4. Requested documentation was not received or received untimely
5. POC and/or certification had no signature.

Palmetto: (scroll to middle of webpage)

1. The recommended protocol was not ordered and/or followed (items on the POC were either not done or not ordered)
2. No documentation to support medical necessity
3. Services performed were not documented (orders must be present and signed/dated for every service)
4. Physician certification or recertification not present/signed
5. Requested records not submitted or untimely

NGS:

1. The actual clinical note for the F2F encounter must be included (such as progress note or facility discharge summary
2. The need for Skilled home health service and homebound must be justified by the documentation in the certifying physician’s and/or acute/post-acute care facility records.
3. When the physician from the acute/post-acute care setting is certifying the patient’s eligibility for the home health benefit and completing the face-to-face encounter, but will not be following the patient after discharge, he/she must identify the community physician who will be following the patient after discharge.
4. It is critical that the home health agency provide the certification and face-to-face encounter documentation from the SOC episode when the claim under review is a recertification claim. 

Hospice Denial Reasons:

CGS: (scroll down over halfway on the website)

1. Terminal prognosis of six months or less is not supported
2. Notice of election is invalid because it does not meet statutory/regulatory requirements
3. Physician’s narrative statement was either not present or not valid
4. Documentation requested was not received at all or received in an untimely manner
5. Physician services were not reasonable and necessary or were administrative in nature including review, supervision and update of the care and services noted in hospice care plan.

Palmetto GBA: (top of page)

1. Provided Information Doesn’t Support a Terminal Prognosis of 6 Months or Less
2. Invalid Election Statement—Unmet Statutory/Regulatory Requirements
3. Physician Narrative Statement Was Not Valid or Was Not Present
4. Face-to-Face Encounter Requirements Aren’t Met
5. Documentation Indicates that the General Inpatient Level of Care Wasn’t Reasonable or Necessary

Be proactive! Does your organization use pre-bill audits?

Corridor’s team of clinical documentation experts’ help ensure billing compliance by performing a clinical or technical review prior to submitting a claim.

We can also assist in every step of an ADR request, denial and/or reconsideration and help avoid future denials!

Partnering with Corridor means you’ll receive ongoing education and improvement initiatives to ensure compliant, efficient and accurate workflows while maximizing reimbursement.

Click here to get started or learn more about Corridor’s Clinical Documentation Advisory Services!

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About Corridor

Corridor is the nation’s preferred partner and trusted business advisor to home health and hospice providers, providing quality services and impactful results for 30 years. Focusing on key operational, regulatory and financial challenges, Corridor delivering industry-unique solutions and deep expertise in coding, clinical documentation review, compliance, billing and collections , consulting and provider staff education . At Corridor, we make the business of caring for people Better! For the most important industry updates and news that impacts home health and hospice, please make sure to sign up for our weekly newsletter to receive the latest up-to-date industry information direct to your inbox!

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