NGS Resumes Home Health Medical Record Review

NGS will resume medical record review after suspension from Public Health Emergency

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

Colleen’s Corner: Targeted Probe and Educate (TPE)

Did you know that National Government Service (NGS) is focusing one of the home health Targeted Probe and Educate on therapy utilization?

Therapy TPE Audits Lead to Home Health Denials

Did you know that National Government Service (NGS) is focusing one of the home health Targeted Probe and Educate on therapy utilization?

NGS is auditing home health rehab service concentrating on medical necessity, the timeliness of the 30-day reassessments that is performed in conjunction with an ordered therapy service, and the required reassessment content by each rehab discipline. For many of the denials, the reasons stem from the therapist not comparing the present assessment results to prior assessment measurements and failing to document the effectiveness of therapy, or lack thereof, as required by regulation.

It may be beneficial to review with your therapy staff the key components to the therapy reassessment documentation as outlined by CMS.

  • Each rehab discipline must document measurement results of functional reassessment compared to prior measurements
  • Each must also document why therapy should be continued or, if applicable, discontinued
    • Document therapist’s determination of effectiveness of therapy
    • Why therapy is beneficial?
    • Why does the patient need more?
  • Remember the re-assessment is only one component of the home visit; there must be evidence of an ordered intervention as well.
    • Document treatment performed the day of re-assessment
    • Re-assessment without care plan interventions is a not covered service

Be Aware…

If measurement results do not reveal progress toward goals and/or do not indicate that therapy has been effective — then, to continue therapy — there must be consultation with the physician and documentation showing why the therapist and physician determined therapy should be continued.

Don’t forget to confirm continuation of the therapy with the verbal order!

I hope to hear from folks who are experiencing any of these issues with the therapy TPE.

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.

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