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Navigating the Surge in TPE and Other Audits

    The home health industry is experiencing a recent surge in medical reviews/audits, posing challenges for many home health agencies. Most audits that home health agencies are receiving through Medicare Administrative Contractors  (MACs) are Targeted Probe and Educate (TPE) audits, which were reinstated in September 2021 after being suspended during the COVID-19 Public Health Emergency (PHE). It is crucial to understand how the specific type of audit you’re undergoing works, so you can prepare to respond accordingly.

    How TPE works

    TPE aims to identify and rectify improper payments by focusing on providers with high claims denial rates or unusual billing practices.  Let’s take a closer look at the three main components of TPE:

    Target: This phase identifies errors or mistakes through data comparison with other providers.

    Probe: It involves examining 20 to 40 claims to get a clear understanding of the provider’s behavior without overburdening them.

    Educate: Providers receive one-on-one personalized education to help reduce claim denials and appeals.

    Common claim errors include missing signatures from certifying physicians, documentation not meeting medical necessity, and incomplete certification or recertification documents.

    When a provider undergoes a TPE audit, they receive a letter explaining the process. The MAC then reviews between 20 to 40 of their claims and supporting medical records. If discrepancies are found, the provider has 45 days to address them after receiving education. If issues persist after this, the process repeats. Failing three rounds could lead to referral to the OIG or CMS, or even facing audits by UPIC or SMRC.

    Responding to TPE and other audits

    Engage with reviewers and ensure they see your cooperation. When compiling charts, have them clinically reviewed to ensure all necessary information is included. Although conducting routine QA reviews on OASIS and visit notes is valuable, performing a comprehensive chart review can greatly enhance consistency across all documentation. It ensures diligent follow-through on orders and care plans and validates the documentation of medical necessity. 

    TPE denial percentages are calculated after each review level, and exceeding the acceptable denial percentage triggers advancement to the next round. Whenever you receive a subjective denial, like insufficient documentation for medical necessity, you have the opportunity to request attestations from clinicians or physicians along with additional documentation. Exhaust all options and remain hopeful.

    Other audits

    Other levels of medical review/audit include UPIC audits, SMRC audits, and CERT audits, which affect most agencies at least twice a year. These audits typically focus on one or two charts. Recovery Audit Contractor (RAC) audits also have gained prominence in home health and hospice since the conclusion of the PHE. These recovery audits are overseen by a single audit company, Performant, and usually involve the examination of one or two charts at a time. It is essential to respond to them just like any other audit. 

    Additionally, there also has been a noticeable increase in OIG audits where charts are sent directly to the OIG for medical review and response. Appeals are directed back to the OIG for evaluation rather than following the standard appeals process.

    Regardless of the review level an agency is facing, it is crucial to be fully cooperative and respond promptly. Timely appeals for any denials are especially important.