TPE audits are back. Is you team prepared? Here are some tips to help you along the way.
The Centers for Medicare and Medicaid Services (CMS) resumed Targeted Probe and Educate (TPE) audits in September 2021 after suspending them during the COVID-19 public health emergency. Now that they are back, it is time to refresh your understanding of the TPE audits and identify the steps necessary for success.
CMS designed and implemented the TPE audit program to increase claim accuracy through one-on-one training for hospice providers. Medicare Administrative Contractors (MACs) use hospice claims data to identify errors and help organizations correct those errors. Hospice agencies are identified for a TPE audit based on their claims error rate and claim discrepancies compared to their peers.
Selected for a TPE audit?
What happens once your agency is selected for a TPE audit? Your organization will receive a letter from your MAC notifying you of the TPE audit. Make sure all mail from your MAC is opened promptly and forwarded to the appropriate person. This is not a letter you want sitting in someone’s mailbox while they are on vacation for two weeks!
The MAC will request 20-40 specific claims and their supporting documentation. Topics for TPE audits can include high-risk patient populations such as:
Long length of stay (>730 days) and non-cancer diagnosis
Long length of stay (>180 days) and non-cancer diagnosis provided to patients residing in long-term, skilled, or non-skilled nursing facilities.
Other areas of focus include:
Live discharges no longer terminally ill
Revocations of the Medicare Hospice Benefit
Live discharges days 61-179 days (when reimbursement rate decreases and prior to Face-to-Face)
Long length of stay (>180 days)
Routine home care provided in assisted living facilities
Routine home care provided in nursing facilities
Routine home care provided in skilled nursing facilities
Claims with a single diagnosis code
Hospices whose claim submissions do not include any days where general inpatient or continuous home care were provided
Once you submit the supporting documentation for the claims, what happens next?
Claims and supporting documents are reviewed for compliance. Agencies whose documentation and billing are 100% compliant will not receive another TPE audit for another year on the same topic. Successfully passing an audit for Revocations does not mean your agency won’t be audited again for Live Discharges. Agencies who have some claims denied will be offered a one-on-one education session to correct the identified issues. Common issues include:
Signature of the certifying physician is missing
Encounter notes do not support all the required elements of eligibility
Documentation does not demonstrate medical necessity
Initial certifications or recertifications are missing or incomplete
Once you have either completed your one-on-one training session or declined to participate in the offered training session, your agency has 45 days to make changes in your processes and demonstrate improvement. If you fail to demonstrate improvement, you enter the second round of TPE, followed by a third and final round if improvement is not demonstrated.
Agencies who continue to have issues in the third round are referred to CMS for further review via measures such as 100% prepayment review, extrapolation audits/payments, or referral to a recovery audit. Each of these measures poses a significant risk to your agency’s cash flow and reputation. Fortunately, this is a rare occurrence in the hospice industry, with less than 2% of the 13,500 hospice providers started on TPE between October 2018 and September 2019 failing all three rounds of TPE. Approximately 435,00 claims were reviewed in that period, and 60% were identified as correctly billed.
How does all this impact you and your organization?
Are you reassured that 60% of all claims reviewed were accepted as they were billed? Can your organization afford to have 40% of your billing delayed? For most agencies, the answer to these questions is NO! Do you have the structure and processes to gather the supporting documentation for 20-40 claims and submit it on time? Do your pre-COVID-19 processes still work if much of the administrative staff are working from home? Many agencies answer no to these questions as well. You must address these issues right away. Don’t wait until you receive a TPE letter in the mail!
Your agency is still struggling with staffing issues as the COVID-19 pandemic continues. Many of your staff were oriented during COVID and have not had the mentoring your organization is known for. Your quality program resources are stretched thin, addressing all of the changes coming with the new Hospice Wage Index. How do you best use your scarce resources?
Your quality and claims data can give you insight into areas where your agency is at risk. Look for areas where your Program for Evaluating Payment Patterns Electronic Report (PEPPER) indicates your claims vary significantly from those of other agencies on a local, state, and national level. Most of the focus areas for TPE are found in the PEPPER report, so you can see where you need to focus your resources.
Identify your areas of highest risk first. Next, ensure you have an auditing system in place to address those issues. Perhaps you have a concern about the number of long length of stay patients with a non-cancer diagnosis. Create a list of the specific patients in this group. Ensure each chart is audited and any areas of concern are identified right away.
Get feedback from frontline staff as to what challenges they experience in caring for long length of stay patients and what is working well. Identify knowledge and process gaps and develop a plan based on the gap analysis. Education and coaching related to assessing and documenting eligibility may be needed. Perhaps staff needs feedback on the use of comparative statements to document decline over time.
You’ll likely need a mix of additional resources, process improvement, and education. Understanding exactly where your gaps are and what you need allows your organization to mobilize scarce resources in the most efficient and impactful way.
Messaging for success!
CMS reminds everyone that when Medicare claims are submitted accurately, everyone benefits. Both CMS and hospice agencies avoid spending time and resources correcting errors and addressing potential fraud and abuse. Cash flow is improved when claims are submitted and paid without the need to submit supporting data and the accompanying delays.
While your organization’s selection for TPE can be frustrating and the work required daunting, it is essential that the message to your organization is one of process improvement, an opportunity to showcase strengths and identify opportunities for improvement.
Gather your internal resources, reach out to industry leaders in education and process improvement, and work towards the common goal of improving the processes that show the exceptional care your organization provides each and every day.