Targeted Probe and Educate – 2019 CMS National Provider Compliance Conference

ANNOUNCER: Centers for Medicare and Medicaid
Services 2019 CMS National Provider Compliance Conference, Targeted Probe and Educate (TPE),
Laura Minter, Senior Director, Novitas, Ronda Tipton, Manager, CGS, Shanda Gustafson, Manager,
Noridian, Kim Hinson, Director, Palmetto. LAURA MINTER: Good morning everyone. We’d like to welcome you to the Targeted
Probe and Educate presentation. Before we begin we thought we’d introduce
ourselves. My name is Laura Minter. I’m the Senior Director at Novitas Solutions
and the Program Integrity Department, our division reports directly to me. RONDA TIPTON: Hi, good morning. My name is Ronda Tipton. I am with J15 CGS and I am the Home, Health
and Hospice Medical Review Manager. SHANDA GUSTAFSON: Good morning. My name is Shanda Gustafson. I am the Medical Review Manager for Noridian
for Jurisdictions A and D. KIM HINSON: Good morning. I’m Kim Hinson. I am the Medical Review Operations Director
at Palmetto GBA. LAURA MINTER: So now we want you to sit back
and relax and let us share with you some more of the ins and the outs of the Targeted Probe
and Educate or TP and E process. For those of you that aren’t too familiar
with the TP and E approach, you’re in the right place, because today we want to talk
to you about the details or the steps in the TPE process, but most importantly the benefits
of TPE reviews. Our goal when we embark on a TP and E journey
with you is to make sure that we outline the rules, the expectations, the requirements
and the goals of the review before we even get started reviewing any claims. And then provide complete comprehensive education
at the conclusion of the review. As all of us were gathering our thoughts and
ideas that we were going to use to compile the PowerPoint presentation that you’re
about to see, we came to the conclusion that this session really should be called Improving
the Provider Experience, because we really feel that this new and improved review process
enables us as contractors to help you navigate through what might seem to be uncharted or
rough waters. There’s been a lot of outreach conducted
and educational materials published not only by CMS but by all of the contractors in an
attempt to ensure that providers clearly understand the TP and E process. We want to make sure that before we start
a review each one of you knows what to expect and to make sure that there’s no surprises
during the course of our reviews. The expectations should be clear. We want to deliver the results of a review
that are advantageous to both of us, but specifically to you as Medicare providers. In order to deliver those results we have
to be clear on what our objectives are. We want to outline for you what to expect,
when to expect it and how we will measure the outcomes of the review itself. TP and E is a process where two-way communication
is the key to maximizing the value of these reviews. Neither one of us will benefit if we aren’t
clear on the process, the expectations or how to communicate the key of what we’re
trying to achieve. In case it isn’t obvious for all the presentations
that you’ve seen yesterday, please note that CMS and its contractors have a commitment
to continuous improvement. That’s one of the reasons that we report
and we track so many statistics and we routinely trend the outcomes. When we review our performance and our results
we ask ourselves, what can we take away from the past that will help us become better and
more efficient in the future? How can we effectuate a change that will have
a positive impact on the Medicare program? Simply put, what can we do better? And I think that’s a great question to ask
ourselves not only in our daily business as usual tasks, but also in our personal lives
as well. So let me tell you a brief personal story. When my husband and I got married and decided
to have kids I was torn because I was going to be the first one on both sides of our family
to have to go back to work. But we knew we could make it work. And we had to prove all of the family skeptics
wrong. So I put on my Wonder Woman cape and I went
back to work after our son Brett was born. And we decided, well, really I decided that
Jeff would be the bad guy and he would take Brett to school every day or daycare and I
would be the hero and pick him up at the end of the day. But one day I had to work late, so I called
my husband, Jeff, because back then cell phones weren’t really a thing, so I called him
and I said would you please pick Brett up on your way home? And he said, and I quote, sure, no problem. So when I got home I was very anxious to see
both Jeff and Brett, well, really Brett, and I came through the door and Jeff rounded the
corner and I looked at him and I said, where’s Brett? And I as watched the color drain from his
face, at the same time I looked down at the kitchen table and there were two loaves of
bread, b-r-e-a-d, on the table. So poor Jeff he thought he had exceeded my
expectations by bringing home not one, but two loaves of bread and neither one of us
had picked our son, Brett, up from daycare. So Jeff took off like a mad racecar driver
to go get our son, Brett, from daycare. So this story reminds me of one of my favorite
quotes and it’s actually from Joan Rivers, and she said it doesn’t get better, you
get better. And so we learned very quickly that two-way
communication allows for a clear understanding of a goal by both parties. And it’s critical to the success of any
situation. And so it is with TP and E. We are getting better because of TP and E.
So in order for all of us to benefit we need a goal and we also need a plan to get to that
goal. And in order to deliver maximum results we
need to first be clear in communicating the goal and also confirming that everyone understands
what’s we’re doing, why we’re doing it and when it will occur. So simply put everyone needs to be clear on
the objectives. We all need to understand the value and the
positive effect that these types of reviews have both on the provider and the Medicare
program. Before we implemented TP and E strategy contractors
were reviewing a lot of claims. But we weren’t necessarily providing the
education that we found was needed to effectuate a change in the way some of the services were
being billed and more importantly documented. So as a result, in conjunction with CMS we
decided to enhance the educational portion of our reviews and to provide each one of
you the ability to talk with us one on one to learn more about the Medicare program,
the policies and the procedures specific to the codes that you bill and to learn more
about the applicable national and local coverage determinations, which affect not only how
bill but also how you document your services to Medicare. So one of our objectives specifically during
a TP and E review is to receive or to make sure that you receive a good customer experience
with us. And that’s why we approach our role as an
educator not an auditor. We want to engage you through the entire course
of the review. We want to set you up for success by ensuring
that our TP and E reviews are pleasant experiences, not punitive and that hopefully that allows
you to maximize your billings and reimbursements to the Medicare program. To simplify it, our goal is two-fold. First, we want to reduce the errors to the
Medicare program by providing education on those elements that will help you maximize
your billings. And as you’ve heard yesterday there’s
some work to be done with a 2018 projected improper payment rate of 31.6 billion dollars. But also along with that we have to ensure
that all the services that are billed to the Medicare program are both reasonable and necessary
and documented in accordance with all applicable policies and procedures. We need to accomplish these goals while allowing
you to provide the best care possible for your Medicare patients. And so while we know that meeting these requirements
may prove challenging, we welcome the opportunity to work with you to meet these objectives
through the use of TPE reviews. So without further ado let me turn it over
to my colleagues from CGS, Noridian and Palmetto who will further discuss the Targeted Probe
and Educate process. RONDA TIPTON: Okay, so as we talked a little
bit yesterday and we’re going to pick up on that again today, let’s talk about a
little bit of background of how medical record review worked prior to the implementation
of TPE. So we had probe reviews, which could either
be service specific or provider specific and also targeted reviews, which again could be
service specific or provider specific. With the probe reviews when providers or suppliers
were identified of having some billing variances from their peers then we would do what’s
called a probative check to see if those errors were significant or if they justified moving
on into a more in depth review process. So a small sample of about 20 to 40 claims
would be selected and then education would be provided and it was very generalized. It could either be through a letter, publishings
to our website, very basic generalized education. It wasn’t specific to the provider. So the 20 to 40 claims would ensure that the
sample was large enough to ensure confidence in the results, but small enough to decrease
the provider burden. There were also service specific probes where
we’d take about 80 to 100 claims. They would be not specific, but very generalized
to an item or topic. And again the education that was provided
during that process was very non-specific to the providers, issues or problems or concerns. So if providers stood out in those areas they
could be moved into more targeted review. With the targeted review then the providers
were put on an edits and there was a much larger selection of claims, more than just
the 20 to 40. It would be a percentage of the provider’s
claims. The thing with the targeted review is that
it could be an ongoing, continuous cycle. And this is what we saw a lot of times. We would do the reviews, we would evaluate
the results, give basic generic information and then the provider would go through the
whole process over again. And so providers could be on targeted review. And what we saw was a lot of them were on
targeted review for years and it was just a repetitive cycle that they never got off
of. We did provide education. Again, it was very generalized and not specific
to the providers’ issues, concerns, or needs. So with that, we transitioned into targeted
probe and educate. CMS released CR10249 October 1st of 2017,
the MACs implemented TPE. It’s provider specific as we’ve all talked
about during this process. And it’s individualized based on what’s
going on with the provider, the billing issues that you’re seeing and the questions and
concerns that you may have. It includes up to three rounds of review with
20 to 40 claims being selected per round. And then in between each round 45 days is
given between the end of the round to the beginning of the next round, so that providers
and suppliers have the opportunity to correct any errors or mistakes that they may have. The goal of TPE is to decrease the billing
error rates. It’s to decrease the appeals because we
know the appeal’s backlog has been ongoing for quite some time and appeals can be very
costly. It’s also to decrease provider burden. And I know I said in my presentation yesterday
when I say this a lot of times people laugh and you know kind of decrease provider burden. But with the education being so specific to
your needs, it prevents those ongoing years possibly, potentially of review. And so it’s broken down into potentially
three reviews instead of ongoing multiple years. We’ve increased our education as we’ve
all been talking about throughout this conference that providers get education one on one. We want to make sure as MACs that we are giving
you the information that you need to be able to successfully complete your review process
and come off of Targeted Probe and Educate. We are doing one on one education in inter
probe, meaning we’re reaching out to providers when there’s easily curable errors in addition
to the post probe one on one individualized education that occurs at the end of Targeted
Probe and Educate round. And then we’re also providing time for the
error correction before we move onto the next round, which as we’ve talked about is a
minimum of 45 days. The focus of TPE is specific to providers
and suppliers and how providers and suppliers are identified through Targeted Probe and
Educate is a lot of internal MAC data analysis. So we do our own data analysis to determine
if providers are standing out from their peers in certain areas. It also could be as a relation to the cert
(ph.) error, are there providers or suppliers who have high cert error rates, are there
issues that they have that are contributing to the cert error rates? And also providers can be put and suppliers
can be put on Targeted Probe and Educate as a result of referrals. So as a MAC we do get referrals from state
agencies, from CMS, from UPIX (ph.), from multiple different places and that could justify
and warrant a TPE review for your provider or supplier. We focus on the high national error rate to
decrease that. And ultimately our goal is to decrease improper
billing and protect the Medicare trust fund. And with that I’m going to turn it over to
my colleague Shanda with Noridian. SHANDA GUSTAFSON: So how does TPE work? I would like to start at a high level and
then I’ll go on and break it down for you a little further as I go. So first you’re notified by your MAC that
a review will be taking place. Then you would begin receiving ADRs for like
Ronda said typically 20 to 40 claims. There is one exception in the DME world there
is a ten claim preview pilot that is currently underway where the first round starts with
only ten claims. Then you would be given or start receiving
ADRs for typically 20 to 40 claims. And once those ADRs are received you will
gather your documentation and provide that to the MAC. The MAC will then review those claims and
documentation, they’ll provide education, look for areas of concern or errors and then
you would receive the official findings. So let’s go over that a little deeper and
this is a visual just to help you see the process. So if chosen for the program you receive that
notification letter from the MAC. The MAC again reviews 20 to 40 claims with
the documentation that you returned in response to those ADR letters. If compliant you will not be reviewed again
for that item or service for at least a year. If errors are found you will be invited to
discuss them in a one on one educational environment. Following education you will be given at least
45 days to make improvements before the subsequent round would begin. This process may be repeated up to three times. So let’s go back to the notification. You will be notified by your MAC with a letter. The appearance of the letter may vary from
MAC to MAC, but generally will include the items shown here, which are explanation of
the TPE process, the service, topic or item that is selected for review, the reason for
that selection, your MAC contact information and notification of the intent for that individualized
education, which is based on the documentation review. After being notified that the review is taking
place, you will begin to receive ADR letters in which the MAC will request documentation
to support the claim that is indicated on that letter. The ADR letter will be available to you via
mail and an online MAC portal if that is available from your MAC and for Part A it may also be
available via FISS, which is the Fiscal Intermediary Standard System. As the ADR letter will state documentation
should be returned to the MAC within 45 days to avoid a denial for non-response. These responses may be mailed, faxed or submitted
via esMD, if you are subscribed to that service. esMD is the Electronic Submission of Medical
Documentation. And more information about that service is
provided on the CMS website. We would like to share some dos and don’ts
about preparing documentation and submitting documentation. Do place the ADR first. Put that on top of your submission packet. What this does is it makes the sorting much
more efficient when it comes into the MAC. Please ensure that all requested documentation
is included. The ADR generally lists several items. And just go through that and make sure that
each of those items is included. Include legible signatures or out of stations
and signature logs. So go through the documentation before submitting,
check for signatures. If they’re missing or illegible, please
go back to the provider and ask for an out of station or a signature log that may indicate
who that provider is, so that we can see that. Do not include documentation that does not
pertain to the ADR. The ADR will have the claim on there, it will
have all of the information, and just include that information. Do not use staples, paper clips, and do not
mix single sided and double sided documents. Following these guides will allow for timely
review and processing by your MAC, which subsequently results in quicker decisions for you. Once the documentation is received by the
MAC we sort them, file them, process, review the information and do all that within 30
days. Documentation is reviewed on a post pay basis
in 60 days. During the review you may get a phone call
from the MAC asking for additional information. These occur when the reviewer has determined
there is an error that could be easily cured by a phone call. This is more efficient than going through
the denial process and then sending you through the appeals process. Once there is a final determination, the claim
is processed with the MAC’s decision. And now I will hand it over to Kim Hinson
from Palmetto and she will discuss education and the next steps in the TPE process. KIM HINSON: Okay. So again I will begin with the education process. So the interaction between the clinician and
the provider is a key component of the TPE process. So in addition to the calls for missing documentation
that was just discussed at the completion of the 20 to 40 claims sample one to one education
will be offered by your MAC. Now this education may be offered via different
means, which may include letters, teleconference calls, electronic visits via webinar, or provider
or supplier specific report cards. And also in addition to the one to one education
your MAC will provide, your MAC will also provide you with written results at the conclusion
of the probe. The structure of this information may vary
by MAC, but the letter will typically include all elements listed here, such as a summary
of the probe review, detailed review of claim findings, general education information and
next steps in the TPE process. It will also include your MAC contact specific
information. What happens if your probe results indicate
you are advancing to the next round? Well, the good news as stated earlier before
moving to the next round the MAC will allow at least 45 days for you to implement any
corrective actions that need to be done. So you do have time to review the results,
identify any contributing factors and implement any actions that are required that can correct
those errors that were identified. I do encourage you to work with your MAC during
that timeframe. So again you will have 45 days, or at least
45 days and up to, you know, 56 or even longer sometimes. So again encourage you to take that time and
the opportunity to work on any errors that were identified. However, any problems that failed to be improved
in that timeframe after three rounds that information will be forwarded to CMS for further,
you know, action or further direction on how we should proceed. And lastly, we do come to a close, but we
do want to remind you if there are any changes to your enrollment to ensure that you receive
the important information from your MAC or other contractors for that matter, please
remember to update the applicable CMS 855 form or visit the internet-based PAYCOS (ph.)
for AB providers. DME providers should contact the NSC. We also encourage you to visit your MAC websites
and CMS websites. And there’s lots of good information out
there. So encourage you to visit those. (Applause) ANNOUNCER: Centers for Medicare and Medicaid
Services.

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