Centers for Medicare and Medicaid Services (CMS) expanded the Targeted Probe and Educate (TPE) to include Hospice effective October 1, 2017.  It is important to note, not all hospice agencies will be selected for TPE review. CMS decided that only the hospices that pose the highest risk to the Medicare program would be selected for review. This means an agency either has a high denial rate, or has billing processes that vary significantly from the rest of the market. CMS will be working in conjunction with the Medicare Administrative Contractors (MACs) to select 20-40 pre-payment and/or post-payment records based on claims data for a potential of three rounds of review.

What Hospices need to know about the TPE selection process:

  • If selected for TPE review, providers will receive a letter. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information.
  • MACs choose claims for review based on many factors such as the service-specific improper payment rate, data analysis and billing patterns of the provider.
  • All current MAC medical record reviews are replaced with three rounds of pre-payment and/or post-payment TPE. If the provider’s error rate remains high upon completion of the first round, then the provider is retained for the second and, potentially, a third round of review.
    • Automated reviews and prior authorization directed by CMS are outside of the TPE strategy.
    • Note that any reviews or pilots otherwise mandated by CMS are excluded from this change.
  • The MAC will select the topics for review based upon existing data analysis procedures, including, but not limited to claims data and PEPPER reports.

What happens after you’ve received a TPE review:

  • A letter with the review results will be mailed at the conclusion of each round.
    • Includes the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
  • Tailored education is administered to the agency focused on improving specific issues and preventing other problems from developing.  There will be an opportunity for the provider to ask questions.
    • Education will be offered after each round.
    • Subsequent rounds will begin 45-56 days after individual provider education is completed.
    • Discontinuation of review may occur if appropriate improvement and error rate below the target threshold is achieved during the review process.
    • Education sessions may occur via webinar, web-based presentation, or traditional teleconferences.

Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include:

  • 100% prepay review, extrapolation,
  • Referral to a Recovery Auditor, or
  • other action

Download our Preparation Guide: Targeted Probe & Educate Checklist