CMS Resumes Medicare A Post Pay Probes: ARE YOU READY

CMS Resumes Medicare A Post Pay Probes:

ARE YOU READY

BACKGROUND

The Center for Medicare and Medicaid Services (CMS) has resumed the Targeted Probe and Educate (TPE) program for performing medical reviews. As a result, we are seeing an uptick in Post Pay Med A probes over the past month and anticipate this trend to continue.

WHAT YOU NEED TO KNOW

  •  The TPE program is designed to help providers and suppliers increase accuracy, and reduce claim denials and appeals through one-on-one help
  • Medicare Administrative Contractors (MACs) utilize data analysis to identify providers and suppliers for post-pay probes
  • Providers and suppliers who vary significantly from their peers, have high claim error rates, unusual billing practices, or provide the most risk to the Medicare Program will be selected

HOW DOES TPE WORK

  • The MACs will review 20 – 40 of your claims and supporting medical records
  • If compliant, no further interventions are necessary
  • If claims are denied, you will be invited to a one-on-one education session and have 45 days to make changes
  • TPE review process may include up to 3 rounds of a pre-payment or post-payment probe

CURRENT TARGET AREAS

The recent focus is on the following HIPPS codes: KAGD1, KDGD1, KAGE1, KAXE1, and KDXE1. These HIPPS are comprised of some of the most common Case-Mix Groups (CMGs) captured as well as some CMGs that do not qualify for the presumption of coverage:

  • PT/OT CMG “K”: represents patients in the Medical Management clinical category with a therapy function score of 10-23. All current probes are focused on this CMG for PT/OT
  • Nursing CMG “G”: represents patient captured in Special Care High with a nursing function score of 6-14 and no depression capture
  • Nursing CMG “X”: represents a patient captured at Reduced Physical Function, with a nursing function score of 6-14 and no depression captured
  • NTA CMG “D”: 3-5 points with at least one qualifying NTA diagnosis
  • NTA CMG “E”: 1-2 points with at least one qualifying NTA diagnosis

WHAT SHOULD YOU DO IF YOU RECEIVE A REQUEST LETTER

  • Notify your interdisciplinary team immediately and begin compiling all of the charts and paperwork
  • Please include your Rehab Director and notify Barbara Blatt, Director of Appeals Management for Preferred Therapy Solutions so that PTS can partner with you and support you through the entire probe process
  • A comprehensive and thorough review should be completed prior to submitting any of the records
Preferred Therapy Solutions continues to provide vital information that may impact rehabilitation management, reimbursement policies, and clinical programs, supported by compliance and regulatory requirements that are necessary for a thorough understanding of practices and procedures. If you have any questions, contact Barb Blatt, Director of Appeals Management: bblatt@preftherapy.com