Take Caution — Targeted Probe and Educate Failure Rate Remains High

Posted on 27 Feb, 2019 |comments_icon 0|By Rebecca L. Johnson

Astronomical stakes have yet to deter abysmal results.

Does your home health agency provide services known to have high national error rates? If so, you might want to take extra care to stay off the TPE radar.

Back in November, HHH Medicare Administrative Contractor CGS reported that only one home health agency of the 122 they reviewed under the Targeted Probe and Educate round 1 eligibility and medical necessity probe (5A000) from July 1 to Sept. 30 was found “compliant.”

The news sent shockwaves through the industry and put a good scare in HHAs who feared how they would fare under scrutiny. Now the industry has more news from CGS — and it’s not good.

Different Quarter, Same Results

Dec. 31 ended another quarter with frightening TPE results. After completing 76 TPE round 1 reviews, CGS auditors found only two home health agencies “compliant” in the period, says a new post on the MAC’s website. That’s a 97.4 percent failure rate — with 97.4 percent of reviewed agencies advanced to round 2.

The two HHAs found compliant were among 55 probes for the Eligibility and Medical Necessity edit (5A000). The remaining 21 probes were for the No response to Additional Development Request edit (5A004), CGS says. There were no compliant findings for that edit.

And while the 97.4 percent failure rate does compare favorably to the rate CGS reported for the previous quarter, which was more than 99 percent, the negligible improvement offers negligible comfort.

New: For the first time, CGS also posts findings for round 2 edits. In the three round 2 probes CGS completed in the quarter, reviewers found all three agencies noncompliant.

Is TPE MAC Quick on the Probe and Slow on the Educate?

The consistent performance results suggest that CGS “is doing a good job with the ‘targeted’ part of TPE and less so with the ‘educate’ portion,” says Joe Osentoski, Reimbursement Recovery & Appeals Director with Quality in Real Time in Troy, Michigan.

When CGS reported results for the first two quarters of TPE, Oct. 1, 2017 through March 31, 2018, about 20 percent of agencies were found “compliant” and 80 percent went on to round 2. That 20 percent compares to a tiny 0.65 percent and 2.6 percent success rate in the two most recent quarters.

The MAC seems able to zero in on agencies that are less likely to respond to ADRs, or whose documentation won’t withstand scrutiny, the latest results imply.

CGS reports that 14 of 55 agencies included for the Medical Necessity edit 5A000 did not even respond, or did not fully respond, to the TPE ADR requests. That fact “supports that they were appropriately targeted,” Osentoski surmises.

“There is no excuse for non-response to ADRs,” Osentoski stresses. “CGS has made substantial information available on how to identify ADRs, a written letter is provided to the agency when placed on a TPE review, and the ADR document itself is a relatively easy document to follow.”

The same pattern of nonresponse “also holds true for the nine of 21 agencies specifically targeted due to their prior Probe & Educate nonresponses that still did not respond to their TPE ADRs,” Osentoski points out.

Bottom line: “Non-response guarantees denials and are of no help to alter the perception of home health waste, fraud, and abuse that is the primary basis for TPE reviews,” Osentoski says.

When agencies do respond to the TPE ADRs, the denials for technical reasons are also frustrating, Osentoski says.

And if the education were working, HHAs would improve between stages of round 1 TPE, and would improve in round 2 TPE. If the MAC education provided after round 1 was effective, “at least some of these agencies should have been found compliant with round 2,” Osentoski says. But all of them failed.

“If the education provided after round 2 is the same as after round 1, that can point towards ineffective delivery of that key information as much as the agency not following it appropriately,” Osentoski maintains.

Of course, targeted agencies may have systemic problems that are too “embedded” to overcome, he allows.

Don’t forget: Failing round 3 will lead to “penalties and drastic actions,” Osentoski warns.

“Any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps,” the Centers for Medicare & Medicaid Services warns on its TPE website. “These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

Note: CGS’s results are at www.cgsmedicare.com/hhh/pubs/news/2019/0119/cope11067.html.

Learn More

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Rebecca L. Johnson
Executive Editor, Newsletters

Rebecca has covered the ever-evolving home health and hospice markets for 20 years, starting about the time the Balanced Budget Act ushered in the devastating Interim Payment System. Under a myriad of payment and regulatory changes, Rebecca has helped home health agencies and hospices thrive and stay compliant. She has also covered markets ranging from internet banking to managed care to physicians. She is an expert on legislation, regulation, reimbursement, operations, business strategies, and more. Rebecca received her Bachelor of Science degree from University of Illinois Urbana-Champaign.

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