National Government Services (NGS) recently contacted Alliance staff to review details for the resumption of medical record reviews. This follows the suspension of the Targeted Probe and Educate (TPE) audit because of the Public Health Emergency. We expect that this review will start this week. All the Medicare Administrative Contractors (MACs) will publish information indicating that medical reviews will resume.
NGS has shared some details with Alliance staff about this resumption, which are summarized below; however, the details are not yet posted on their website.
- NGS will resume post-payment medical reviews. This is different than the TPE program. CMS has not provided any direction to the MACs thus far regarding the resumption of TPE.
- The post-payment reviews are service-specific (as opposed to provider-specific) and will be a random sample. A service-specific review is one where the MAC is focused on the claim and not the provider.
- CMS has given a resumption date of August 17, 2020. It is anticipated that providers will begin receiving Additional Documentation Requests (ADRs) once NGS posts more information on their website. NGS indicated it will post a brief description of the service-specific audits on its website and ADRs will be sent approximately 2-3 days after this posting.
- The timeframe from which NGS will pull claims is January 2019 through February 29, 2020
- The maximum number of claims to be pulled per provider is 20. There is no minimum. This is less than the total number under the TPE program, and a provider may or may not receive ADRs for a full 20 claims. It is anticipated that the majority of hospice and home health providers will not have this many claims pulled. Any providers having difficulty responding to the ADRs on time should contact NGS and they may be able to work with the provider if the provider makes them aware of the situation.
- Providers should not wait to receive an ADR request in the mail, but should check the status of their claims processing and identify any with the S B6001 status. These are claims that have had an ADR generated.
- NGS has 60 days to review the provider’s response to the post-payment ADR. Though providers have 45 days to respond to the ADR, a 30-day response is strongly recommended to ensure that the response is received and recorded by the 45th day.
- A results letter will be sent after each claim is reviewed.
- A provider may request education and the NGS may suggest education. Providers are not required to participate in education, although the Alliance strongly recommends it.
- The error rate (payment error rate or claim error rate) is not as important with a service-specific post-payment review as it is with TPE, since there are no “rounds” in post-payment review as there are with TPE. The MACs are not setting error rate thresholds upon which further NGS action is predicated. As with all medical reviews, if NGS identifies a concern, i.e. a quality concern or indication of potential fraud or abuse, NGS will refer to the appropriate entity (i.e., the appropriate QIO or the division of CMS).
- NGS will continue to make phone calls to providers for missing documentation or questions about documentation submitted.
It is still possible that providers will receive some other ADRs as part of other review programs such as CERT. CMS contractors, including Unified Program Integrity Contractors, may conduct targeted prepayment and post-payment reviews when there is evidence of potential fraud or gaming. CMS has not yet indicated if the results of the post-payment reviews that are resuming this month would be used for future TPE audits.
If you have any questions, please contact Colleen Bayard at firstname.lastname@example.org.