Developing a Winning Home Health Targeted Probe & Educate Medical Review Strategy

Written by Donna Berry | Sep 25, 2017 1:09:00 PM

On January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) required home health agencies (HHAs) to obtain documentation from the certifying physician's and/or the acute/post-acute care facility's medical record for the patient. This served as the basis for the certification and eliminated the face-to-face encounter narrative as part of the certification of patient eligibility for the benefit.

With the elimination of the physician narrative requirement on the face-to-face in 2015, CMS implemented the first “Probe and Educate” medical review strategy. The purpose was to make certain that providers fully understood the new rule and to offer education and compliance guidance when errors were discovered. CMS directed home health Medicare Administrative Contractors (MACs) to select a sample of five claims for pre-payment review from every home health care agency in their jurisdiction. Although the primary focus was to ensure compliance with the new face-to-face requirement, of course the MACs also were instructed to make certain that all other coverage and payment requirements were met.

Because of the success of Probe and Educate which, according to CMS, resulted in a decrease in the number of claim errors, CMS has revised this strategy. In August 2017, CMS introduced the Targeted Probe and Educate Medical Review Strategy (TPE). MACs have now been directed to move from a broad review which included every agency to one that targets specific providers or services. This is great news for the many agencies that were found to be compliant during the original Probe and Educate strategy because they will not be included in a TPE.

The MACs will select topics and/or providers for targeted review based upon data analysis. 20-40 claims per provider, per service, per round for a total of up to three rounds, will be selected. Each round is considered a probe. Following each round or probe, individualized education will be offered. Providers will be given 45 days between rounds to demonstrate improvement following the individualized education. If during any round, the provider is found to be compliant, then their participation in a TPE will be discontinued for at least 12 months. If a provider is found to be non-compliant after all three rounds, then the MAC will refer the provider to CMS for possible further action which may include extrapolation, referral to ZPIC/UPIC, or other actions.

Developing a Winning Strategy for Your Home Healthcare Agency – 7 Recommendations

Here are 7 recommendations that can help your home health care agency leverage this development positively:

It is imperative that providers schedule and receive the education that will be offered after each probe. Many of the providers that will be included in a TPE are those who failed to receive the education that was offered during the original Probe and Educate.
If you are found to be non-compliant and have not received the guidance from the MAC, then contact them and request the education.
Make certain that you read and understand the denial letter that will offer the specific reason for the denial and the rule. Use this as an outline to make certain that the MAC addresses all of your provider-specific issues during the education session.
Educate your staff on the findings from the probe and develop a plan to correct the issues that led to non-compliance.
Develop a process to maintain oversight to prevent further TPEs even if you are compliant. Remember, once targeted, a provider can be targeted again after one year.
Review your agency’s procedure for billing and submitting claims.
Complete a pre-audit chart review prior to submitting any claims—especially Medicare claims.

Medical reviews, whether pre-payment, Probe and Educate or TPE will always be a part of the home health care landscape. Providers must continue to be diligent about remaining compliant and staying informed of the ever changing regulations. Every staff member from the Home Health Aide to the CEO must be held accountable and understand their part in keeping the agency compliant.

For additional information, check out these resources:

Center for Medicare and Medicaid Services. MLN Matters Number SE1524
Center for Medicare and Medicaid Services. TPE Pilot Flow Chart

Contact Richter Healthcare Consultants:

Do you have questions about home health targeted probe and educate medical review strategy, or other clinical challenges? Call Richter’s clinical consultants at 866-806-0799 to schedule a free consultation.

Donna Berry is the Home Health and Hospice Revenue Cycle Manager with Richter Healthcare Consultants.

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