Home Health Recoupments

Has your Home Health Received the Targeted Probe and Educate Letter?

Are your Audit Processes in Place?

CMS implemented the Targeted Prove and Educate (TPE) process, effective October 1, 2017. Based on data analysis of claims payment, CMS will identify areas with the greatest risk of inappropriate program payment. Palmetto GBA selects providers for the TPE process based on the following:

• Analysis of billing data indicating aberrancies that may suggest questionable billing practices or

• On targeted review and is transitioned to the TPE process based on error rate results or

• On service specific review error rate results

CMS will mail a letter to those who have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information.

• TPE consists of up to three rounds of review with 20-40 claims sample selected (pre or post payment) for each round

• Agencies with a high error rate will have a 2nd and 3rd round of audits.

• Subsequent rounds will begin 45-56 days after individual provider education is completed.  Discontinuation of review may occur if appropriate improvement and compliance is achieved during the review process.

• • An Additional Document Request (ADR) will be generated for each claim selected
    – For pre-pay reviews, Palmetto GBA has 30 days from the date the documentation is received to review the documentation, and make a payment decision

• – For post-pay reviews, Palmetto GBA has 60 days from the date the documentation is received to review the documentation, and make a payment decision

Critical items to note:

• Non-response denials count as an error when calculating the error rate.

• When high denial rates continue after three rounds of TPE, Palmetto GBA will send a referral to CMS for additional action.

• Agencies with high denial rates as a result of the Face to Face Probe and Educate during 2016-2017 may not fair well during this review process

• Agencies MUST have a clear understanding of compliant documentation including the face to face rules and documentation of homebound status

• Detailed audit tools and processes need to be in place to ensure proper payment and low denial rates.

• An agencies ability to participate in the Medicare and Medicaid programs can be impacted during TPE.

• • Compliant face to face documentation, adequate therapy justification, and supporting length of stay are the main items of focus. The following risk areas should be of focus:
    – Length of stay
    – Therapy thresholds and justification
    – OASIS coding
    – Signatures and dates
    – Plan of care
    – Homebound status
    – F2F (must show homebound status, need for skilled services, match the 485)

Now is the time for agencies to be proactive, educate staff and do those audits internally to ensure compliance so that when you do fall under TPE, you can pass the first round.