Corporate

TPE Process Targeted Probe and Educate (TPE) Process

Change Request 10249External PDF implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. Refer to the Medical Review Activity Log Web page for a list of home health and hospice review topics. All service-specific and provider specific reviews as well as round two of the Home Health Probe & Educate Program will be phased out.

Key Points

  • CGS 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.
  • CGS 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 up to 20-40 claims selected (pre or post payment) with 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.
  • An Additional Documentation Request (ADR) will be generated for each claim selected. CGS has 30 days from the date the documentation is received to review the documentation, and make a payment decision. Refer to the Medical Review Additional Development Request (ADR) Process Web page to learn how to check if an ADR was generated for your claim.

    Note: No response to ADRs (denial reason 56900) count as an error when calculating the error rate. CGS recommends using myCGS, our secure online web portal to submit documentation in response to medical review ADRs. For additional information, refer to myCGS User Manual Home Health and Hospice Chapter 7: Forms TabPDF for instructions.

    If you are not already registered to use myCGS, refer to the enrollment instructions found in Chapter 1 of the myCGS User ManualPDF.

  • A letter with the review results will be mailed at the conclusion of each round. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
  • Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the home health and hospice TPE email box at J15HHprobeandEducation@cgsadmin.com.
  • When high denial rates continue after 3 rounds of TPE, CGS will send a referral to CMS for additional action.

Resources:

Revised: 02.07.18


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