Home Health Billing Update

For a while now, there have been rumors that the Centers for Medicare and Medicaid (CMS) would be resuming it’s Targeted Probe and Educate Program (TPE) after suspension during the COVID-19 pandemic. These rumors have left many companies responsible for home health billing concerned and wondering if they should prepare. Well, the rumors have been proven to be true. The agency announced that it has resumed audits as of September 1, 2021.

To help you prepare and decide whether you should consider working with home health billing companies for support, we’ve put together an overview that will help you get caught up on the TPE and how CMS is moving forward for this year.

Understanding TPE and Home Health Billing
According to CMS, the TPE program is designed to provide one-on-one help to home health providers like you reduce claim denials [1]. The goal is to help you quickly improve your home health billing processes by working with a Medicare Administrative Contractor (MAC) to find the errors you’re making and helping you correct them.

While most providers will never need a TPE, it’s helpful to understand how it applies to the home health billing process. Providers who might need TPE support include providers who have high claim error rates, exhibit unusual home health billing practices, or who provide items or services that have high national error rates and that are known to be a financial risk to Medicare.

If your claims are compliant with Medicare policies, you won’t be chosen for TPE. But if you’re still wondering what your chances for receiving a TPE notice are, CMS says that between October 2018 and September 2019, around 13,500 providers received a notice and about 435,000 claims were reviewed [2].

Common TPE Mistakes in Home Health
If you’re concerned that your home health billing practices might put you at risk for a TPE audit, it will be helpful to assess whether you’re committing common errors. These include:

  • Not including the signature of the certifying physician on a claim
  • Not including all documentation necessary to prove medical necessity
  • Your encounter notes not supporting all elements of eligibility
  • Your claims missing or containing incomplete initial certifications or recertification

If these are areas that you’ve struggled with in the past or have found challenging since the start of the COVID-19 pandemic, you might want to consider reviewing how home health billing companies can help keep you off the TPE radar.

What the TPE Audit Process Looks Like for Home Health Billing
For home health billing, the TPE audit process is a three-step process in which the second step is repeated if certain conditions aren’t met [2].

Step 1
The home health provider will receive a “Notice of Review” letter from the MAC. This letter will break down the reasons you’ve been selected for review. It will also request that you produce 20-40 records for review.

Step 2
Once you’ve provided the records, your MAC will review the claims, comparing them to the supporting medical records. You will then be sent a letter that details the result of the review. These letters come in a pink envelope and should not be ignored.

Keep in mind that this is a step that will need to be repeated if not properly passed. If some of your claims are denied, you’ll be invited to a one-on-one session for education. You’ll then be given a minimum of 45 days to make changes and improve what went wrong.

Step 3
Once your claims are deemed to be compliant, your audit is complete. You won’t be selected for review again for at least a year unless the MAC finds significant changes in your billing.

If you do still have issues, you’ll be given three audit rounds to pass. If you fail after three rounds, you’ll then be referred to CMS for additional action. These actions can include extrapolation, 100 percent prepay review, referral to a revenue Recovery Audit Contractor (RAC), or another action.

How You Can Prepare
The best way to prepare for a TPE audit is to prevent them. Many home health organizations work with home health billing companies, so the complexity of home health billing isn’t something they take on. But if you do receive an audit, you should take action immediately. When you send the requested records, make sure they are complete and organized so that your chances of passing the first round are optimized.

If you do have to make corrections after a round of education, make sure you are implementing them as efficiently and effectively as possible to increase your chances of passing the audit. A strong initial response can help you avoid being referred to CMS for additional action. You should also be open to working with outside counsel or a home health billing consultant as you go through internal review. This will help you develop a strong defense strategy if you decide to challenge the audit.

Most importantly, if you feel you’re at risk of a TPE audit or don’t have a handle on your claims processes, we want to invite you to contact us so we can discuss strategies for keeping you off the CMS radar.

[1] U.S. Centers for Medicare & Medicaid Services, “Targeted Probe and Educate,” 29 April 2021. Available: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.
[2] T. Fletcher, “Important News: TPE Audits Resume,” 11 October 2021. Available: https://www.icd10monitor.com/important-news-tpe-audits-resume.

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