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!