TPE program: Still a work in progress

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Friday, January 11, 2019

WASHINGTON – CMS has updated its “Targeted Probe and Educate” program in two ways that could potentially make it easier and more fair for HME providers.

The agency on Dec. 31 implemented the “TPE 10-Claim Preview Pilot” to allow the MACs to select just 10 claims for review under Round 1. If a provider is found to be compliant, the NPI associated with those claims will be exempt from reviews for about one year for those services/items.

“In some ways it’s good,” said Kelly Grahovac, a senior consultant with the van Halem Group. “If you have everything that you need, it’s less of a burden, because you only have to respond to 10 files instead of 40 files.”

If the MACs detect errors during the pilot, a provider just goes through the usual TPE program.

But the pilot may put HME providers, whose documentation can sometimes be “subjective,” at a disadvantage, Grahovac says.

“Where I can see a problem is if you have one issue with your process, it affects every claim,” she said, “and it’s a smaller sample from which they’ll determine your compliance rate.”

CMS has also published a new transmittal instructing the MACs to review only services/items with dates of service after one-on-one education for Rounds 2/3 of the TPE program, whereas they can review dates of service or dates of submission for Round 1. The MACs must allow 45-56 days between each education intervention to give providers time to make improvements.

“The intent of the TPE is, targeting an issue, doing an audit or probe, then educating,” Grahovac said. “They need to give you time to fix it, then they can come back and see if you fixed it.”

Industry stakeholders had noted inconsistency across contractors and even reviewers on when an audit was “turned back on,” Grahovac says.

“I think enough folks said, ‘This doesn’t make sense, it needs to be date of service, not date of submission,’” she said.

Grahovac says she’s not surprised by the changes, as CMS considers the TPE program a work in progress. She expects more to come.

“I’d like them to be more consistent on product categories,” she said. “A supplier may get audited on a CPAP and pass, then get an audit for masks and pass, and then get an audit for another supply item. If you’re taking the time to review the main equipment and that documentation looks good, the likelihood is that it’s good for the supplies, too. It’s a bit beating a dead horse.”