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November 29, 2018

Targeted Probe and Educate Progress Update

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249External PDF implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides progress of TPE from October 1, 2017 – September 30, 2018.

Findings

Medical Review initiated complex review edits for specific providers identified through data analysis demonstrating high risk for improper payment. Education has been offered to providers throughout and upon completion of Round 1 of TPE review. Current Round 1 Home Health and Hospice Results are as follows:

Home Health

Probes completed July 1, 2018 – September 30, 2018

Eligibility and Medical Necessity edit 5A000

Results

Home Health

Probes Completed

122

Providers Compliant after Round 1 Completion

1

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

121

Providers with Non-Reponses to ADR’s for Round 1

23

LOS >120 Days edit 5A002

Results

Home Health

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

0

LOS >180 Days edit 5A003

Results

Home Health

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

1

No response to ADR edit 5A004

Results

Home Health

Probes Completed

28

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

28

Providers with Non-Reponses to ADR’s for Round 1

19

Probes completed October 1, 2017 – September 30, 2018

Eligibility and Medical Necessity edit 5A000

Results

Home Health

Probes Completed

160

Providers Compliant after Round 1 Completion

4

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

156

Providers with Non-Reponses to ADR’s for Round 1

32


LOS >120 Days edit 5A002

Results

Home Health

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

0

LOS >180 Days edit 5A003

Results

Home Health

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

1

No response to ADR edit 5A004

Results

Home Health

Probes Completed

40

Providers Compliant after Round 1 Completion

1

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

39

Providers with Non-Reponses to ADR’s for Round 1

21

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Round 1.

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Risk Category

Risk Category is defined based on end of round provider error rate. The categories are defined as:

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Top Denial Reasons July 1 2018 – September 30, 2018

  1. Face-to-Face missing/incomplete/untimely
  2. Initial certification invalid
  3. Medical records were not received
  4. Recertification estimate missing/invalid
  5. Plan of care missing/invalid
  • FTF Documentation Denials accounted for approximately 25% of the total Targeted Probe and Educate denials.
    • Actual FTF encounter document not submitted
    • Certifying physician did not document the date of the FTF encounter
    • Community physician was not identified when a physician who would not be following the patient after discharge signed the certification
    • Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification

      Refer to the CGS Home Health Coverage Guidelines Web page for a variety of resources on the home health FTF encounter.
  • Initial certification invalid accounted for approximately 13% of the total Targeted Probe and Educate denials.

    Refer to the CGS Home Health Physician Certification Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).
  • Medical records were not received accounted for approximately 11% of the total Targeted Probe and Educate denials.

    Refer to the CGS Medical Review Additional Development Request (ADR) Process Web page for information to ensure that necessary steps are taken to submit documentation timely.
  • Recertification estimate missing/invalid accounted for approximately 9% of the total Targeted Probe and Educate denials.
  • Plan of care missing/invalid accounted for approximately 7% of the total Targeted Probe and Educate denials.

    Refer to the CGS Physician Orders, Plan of Care and Certification and Home Health Missing/Incomplete/Untimely Plan of Care or CertificationPDF Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).

Hospice

Probes completed July 1, 2018 – September 30, 2018

LOS with Non-Oncologic Diagnosis edit 5D000

Results

Hospice

Probes Completed

2

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

2

Providers with Non-Reponses to ADR’s for Round 1

0

Probes completed October 1, 2017 – September 30, 2018

LOS with Non-Oncologic Diagnosis edit 5D000

Results

Hospice

Probes Completed

2

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

2

Providers with Non-Reponses to ADR’s for Round 1

0

LOS >180 Days edit 5D002

Results

Hospice

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

0

LOS >120 Days edit 5D003

Results

Hospice

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

0

LOS in LTC, NF or SNF edit 5D004

Results

Hospice

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion (advancing to Round 2)

1

Providers with Non-Reponses to ADR’s for Round 1

0

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Round 1.

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Risk Category

Risk Category is defined based on end of round provider error rate. The categories are defined as:

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Top Denial Reasons July 1 2018 – September 30, 2018

  1. Terminal prognosis not supported
  2. MD services not medically necessary

Education

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.

Next Steps

Providers found to be non-compliant at the completion of Round 1 will advance to Round 2 of TPE at least 45 days from completion of the 1:1 post probe education call date. CGS offers education at any time for providers. Providers do not have to be identified for TPE to request education. CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review Activity Log and using tools such as Comparative Billing Reports (CBRs)PDF offered through our web portal.

References

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