Dear Members,
We know that many of you are currently dealing with Additional Documentation Requests (ADRs) from the Centers for Medicare & Medicaid Services (CMS) as a result of Targeted Probe and Educate (TPE) audits. TPE audits are intended to improve provider billing practices by reducing errors in claims submission, thereby reducing claim denials and appeals, but we understand that the ADRs that often result are difficult and time-consuming, as well.
The Targeted Probe and Educate Process
Agencies with high error rates in their claims or billing/utilization practices that differ significantly from their peers are identified via data analytics at CMS. A provider’s historical performance on previous TPE audits is also considered, and may contribute to the likelihood of their being selected for additional reviews. CMS selects such agencies for an audit, with the goal of improving their billing through counseling and education. Our regional Medicare Administrative Contractor (MAC) for Texas, Palmetto GBA, will inform you via letter if your agency is selected for a TPE audit, and will review between 20 and 40 of your claims for compliance with CMS requirements. Agencies deemed compliant by the MAC will not be reviewed again for at least one year, as long as no significant changes in their billing practices are identified after the review.
Agencies deemed non-compliant with CMS requirements will have their claims denied/suspended and will be asked to attend a one-on-one training session with provider education staff at Palmetto GBA. These sessions are designed to help providers identify mistakes they may be making when submitting their claims and supporting documentation, and correct them. Providers have 45 days to make the necessary corrections and improve their claim submissions; providers who do not improve within this period will be subject to additional rounds of claim review and education.
Common Mistakes on Claim Submissions
- Missing certifying physician signature
- Missing/incomplete initial certification or recertification information
- Documentation submitted does not demonstrate medical necessity for services
- Face-to-face encounter notes do not support client eligibility for services, including:
- Failure to document the patient’s homebound status; and/or
- Failure to demonstrate the patient’s need for skilled services
Help for Responding to ADRs
It is critical that you indicate your agency’s designated contact person by name, including their contact information, with all records you submit when responding to your ADR(s). The MAC reviewer will contact this person to discuss the results of your agency’s review, and may request additional documentation from them over the course of the review in an effort to prevent claim denials.
Palmetto GBA provides helpful education and guidance for responding to ADRs. Providers may wish to refer to Palmetto’s Home Health ADR Checklist when developing their responses, as it covers critical information that must be provided, including:
- Plan of Care and Certification/Recertification
- Signatures
- OASIS
- Face to Face Encounter
- Documentation of Services Rendered
CMS’s Medicare Learning Network (MLN) Matters SE1436, Certifying Patients for the Medicare Home Health Benefit, also offers helpful guidance on many of the required elements noted here.
In addition, Palmetto GBA offers excellent general instructions agencies should follow when responding to ADRs, some of which include:
Provide the documents listed on the ADR and any related physician’s orders. Make sure the physician's signature is legible or include an attestation of signature.
Include a copy of the ADR with your documents. When returning ADR responses for multiple claims, be sure to pair each ADR letter with the corresponding documentation. Pairing these documents ensures the documentation for each request letter is correct for each date of service requested.
Include a completed Medicare Medical Review ADR Response Cover Sheet. Use one ADR Response Cover Sheet for each ADR letter/claim.
Do not submit documents by more than one method, as a duplicate response slows down the documentation review process.
Return your ADR response to Palmetto GBA within 30 days of the date on the ADR letter. The claim will automatically deny by the 45th day if a response has not been received. There is no guarantee that any responses received between day 30 and 45 will be processed prior to the claim being denied.
Please visit the Palmetto GBA ADR post online for full details on these instructions.
Additional Helpful Resources on TPE, ADRs, and Face-to-Face Encounters from CMS and Palmetto GBA
Improving the Medicare Claims Review Process: TPE Info Sheet
Targeted Probe and Educate (TPE) Q & A’s
Medical Review Targeted Probe and Educate (TPE) Process Hot Topic Teleconference Questions and Answers – June 19, 2018
Responding to Home Health Additional Documentation Request (ADR) Checklist
Home Health Face to Face Checklist
Medicare Home Health Face-to-Face Requirement PowerPoint Presentation
MLN Matters SE1436, Certifying Patients for the Medicare Home Health Benefit
Face-to-Face Encounters and Certification for Home Health Care and Physician Documentation Requirements letter to Physicians
Home Health Face-to-Face Encounter Question and Answers
The TAHC&H member forums are also helpful sources of information and guidance from other providers who have been through the TPE/ADR process. Please don’t hesitate to reach out to your peers there, or to contact the staff here at TAHC&H for assistance.
Thank you!