Haunted by TPE? Don’t Let It Frighten You!

Many home health care agencies have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE). Here are answers to many common questions.

Many home health care agencies (HHAs) have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE), so I thought I would review the rules because I am sure others have the same questions. NGS has contacted HCA to let us know that there are new TPE audits in Massachusetts: high therapy utilization, long lengths of stay, documentation supporting homebound for Heart Failure, COPD, Diabetes and Dementia, and medical necessity.

How Will the HHA Be Notified:  Agencies will receive a letter from NGS stating the focus of the targeted probe. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records. If you are currently in a TPE audit you will not be chosen for another. If for some reason you receive another TPE please contact Colleen Bayard because agencies should only be under one targeted probe and educate for home health at a time.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: Agencies will be notified of one-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

HHAs are Experiencing New Round of Targeted Probe and Educate

National Government Service (NGS) announces two new rounds of Targeted Probe and Educate (TPE) for home health agencies

Last month, the National Government Service (NGS) notified the Home Care Alliance of Massachusetts about two new rounds of Targeted Probe and Educate (TPE):

High therapy utilization. NGS will be reviewing documentation to ensure all CMS requirements have been met on therapy assessments and 30-day reassessments, as well as, medical necessity.

Documentation supporting homebound criteria. The second edit is specific to four diagnoses: Heart Failure, COPD, Dementia, and Diabetes and if the documentation confirms homebound status.

Many HHAs have contacted me over the past few weeks with questions about the TPE, so I thought I would review the rules because I am sure others have the same questions.

How Will the HHA be Notified: You will receive a letter from NGS stating the focus of the targeted probe: high therapy or homebound for one of the four diagnoses listed above. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: One-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

If you have any questions or concerns about TPE, it would be great to hear from you. Good Luck!

Members Flock to HCA’s Quality Improvement Meeting

Lots of member interest in HCA’s July QI meeting to discuss medical record audits and upcoming proposed rule changes.

With the sundry of regulation changes in the home health industry over the past few months, the July 24th Quality Improvement (QI) meeting had over 45 members participating in-person and by phone. The numerous medical record audits plaguing the industry dominated the meeting’s discussion.

Multiple agencies have received letters from C2C Innovation Solutions informing them that some claims under appeal have been selected for potential reopening as part of the Medicare Appeals Demonstration. The C2C auditors are conducting the analysis of claims previously adjudicated unfavorably by the Qualified Independent Contractor (QIC), that are currently pending at the Office of Medicare Hearings and Appeals (OMHA) and may be resolved favorably by the QIC.

Other audits that agencies are experiencing are new Targeted Probe and Educate (TPE) audits. These medical record requests are for 5-7 visits and lengths of stay greater than 90 days. No agency is in the third round of the Face-to Face TPE.

One agency reported at the meeting that they are facing three audits simultaneously; a hospice General Inpatient care (GIP) Targeted Probe from NGS, a home health PERM request for Face-to-Face (awaiting ALJ) and eight GIP Post Payment Review by Noridian.

During the meeting there was a lot of member engagement related the 2020 Proposed Rule; the proposal to require OASIS for all payors and the 8% behavioral adjustment. Agencies also discussed strategies for management with PDGM and the process for completing OASIS B-1 for January 1st episodes. PDGM will be a standing QI agenda item.

The HCA is planning to host a PDGM Networking Meeting to help our members with the transition to this new payment model. We are hoping to begin the meetings in September and have a guest speakers and consultants to assist with planning for this historic payment change. Stay tune for further details.

Don’t forget to check out our PDGM Bootcamp on September 24th!

Let Our CoPs Manual Be Your Roadmap to Compliance

The Home Care Alliance of MA put together a COP Task Force consisting of an expert team of home health professionals. This task force developed guidelines to assist Home Health Agencies with the understanding on the new standards in order to stay in compliance.

Though the CoP Guide is available to Alliance members at no cost (log-in required), non-members may purchase an electronic version on our website. Upon purchase, you will receive an email with a link to download the PDF.

Return to www.thinkhomecare.org.

Talking Home Care Episode 4: NAHC’s Bill Dombi on HHGM and Federal Home Health Policy

Pat Kelleher talks with NAHC’s Bill Dombi about PDGM, reduced CMS spending, and more.

Bill Dombi
Bill Dombi, Interim President of NAHC

For the fourth episode of the Talking Home Care podcast, Pat Kelleher talks with Bill Dombi, interim president of the National Association for Home Care & Hospice (NAHC). Topics include:

  • Background on the the Home Health Grouper Model (HHGM) and an update on its status;
  • Discussion of the $950M/year reduction in overall home health spending, as estimated by CMS (and estimated to be much, much higher by NAHC);
  • An update on NAHC’s lobbying efforts, specifically its support of a letter sponsored by Senators Nelson and Rubio to oppose the new model;
  • How we need agencies to contact their representatives immediately (by the end of the Monday, September 25);
  • How cuts may affect the home health workforce; and
  • Holding the Trump Administration to its promise to reduce paperwork administrative overhead.

You may listen to the podcast by clicking the play button above, downloading it directly, or subscribing through iTunes or Google Play. (Length: 29’00”; Size: 14 MB).

Links/Action:

Talking Home Care LogoHost: Patricia Kelleher is the Executive Director of the Home Care Alliance of Massachusetts.

Guest: William Dombi was appointed as NAHC’s interim president this past August, and served as its vice president for law since 1987. He is also director of the Center for Health Care Law, a nonprofit, public interest law firm established by NAHC, and executive director of the Home Care and Hospice Financial Managers Association. Additionally, he is a member of the advisory board of Bloomberg BNA’s Medicare Report.


Don’t want to miss the next episode of Talking Home Care? Subscribe through iTunes, Google Play, or enter the following in your podcast app: https://thinkhomecare.wordpress.com/category/talking-home-care-podcast/feed/

Return to www.thinkhomecare.org.

CMS to Delay Expansion of Pre-Claim Review Demo

CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.

According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October.  This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.

According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.   The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida.

The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project.  Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.

Return to www.thinkhomecare.org.

Home Care’s Part in the CMS Bundled Payment Program for Cardiac Care

Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.

CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.

CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.

  • Waiver of direct supervision requirement for certain post-discharge home visits:
    • “CMS waives the requirement in  § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section.  The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
  • Waiver of certain telehealth requirements:
    • “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the  geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes  being tested in an EPM, but only for services that  (1)  May be furnished via telehealth under existing requirements; and (2)  Are included in the episode in accordance with  § 512.210”
    • The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
  • Waiver of the SNF 3-day rule
    • Only applies to the AMI (Acute Myocardial Infarction) model.

There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:

  • Barnstable Town, MA
  • Boston-Cambridge-Newton, MA-NH
  • Providence-Warwick, RI-MA

Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.

Return to www.thinkhomecare.org.