CMS Resumes Targeted Probe & Educate Audits

WASHINGTON, D.C. (September 7, 2021)—The Centers for Medicare & Medicaid Services (CMS) indicated in an August 2021 MLNConnects newsletter that the agency will resume the targeted probe and educate (TPE) program that was suspended in March 2020 (as were most medical reviews) due to the COVID-19 public health emergency (PHE).

Some medical reviews resumed in August 2020, despite the PHE, but the TPE program remained on pause.

The announcement to resume TPE did not provide an exact date for resumption, but one Medicare Administrative Contractor (MAC), Palmetto, has indicated on its website that TPE began again on Sept. 1, 2021. At the time of publication of this article, the other MACs have not posted any information to their websites regarding this TPE development.

The National Association for Home Care & Hospice (NAHC) has heard from home health providers that they have received letters from their MAC indicating that any previous TPE cycles that were open at the time of the TPE suspension due to the PHE would be closed and the provider removed from the TPE program. The provider could be placed on the program again should they meet the criteria for the new data runs that the MAC will be conducting.

It is not clear why CMS chose now, when the pandemic is worsening, to resume TPE. Providers continue to feel pressure from COVID-19 related stressors, such as inadequate staff with increasing high acuity patient referrals. TPE places significant burden on providers during ordinary times, let alone during times when COVID-19 surges and natural disasters are occurring concurrently. Many home health and hospice providers simply do not have the resources during this time to adequately comply with a TPE process that requires 20-40 additional documentation requests.

Therefore, NAHC is urging CMS to reconsider resuming TPE and suspend TPE until the PHE has ended. The American Association for Homecare has also flagged potential issues with restarting TPE, and requested CMS to be mindful of the challenges home medical equipment suppliers face during these uncertain times. 

If suspension of TPE until the end of the PHE is not possible, CMS should instruct the MACs to not subject providers to TPE if responding to medical review requests will create an undue burden due to the PHE and/or responding to natural disasters.

As a reminder, the TPE program differs from the current post-payment service specific review audits that some providers have experienced, in that it targets providers rather than specific services. TPE is intended to increase accuracy in very specific areas. MACs use data analysis to identify:

• providers and suppliers who have high claim error rates or unusual billing practices, and
• items and services that have high national error rates and are a financial risk to Medicare.

TPE consists of up to three rounds of review with a 20-40 claim sample selected (pre- or post- payment) for each round. Providers will receive a letter from their MAC notifying them of selection in the TPE program and the reason why to be followed by the Additional Documentation Request (ADR) for specific claim records.

Each MAC posts TPE topics on its website; however, at the time of publication of this article only Palmetto had posted this information, which can be found here.

Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.