Dear Members,
Palmetto GBA’s Medical Review staff initiated
TPE Probe review edits for providers identified through data analysis demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the Probe 1 TPE review. Current Probe 1 Home Health TPE Results for the period from October 1, 2017 to September 30, 2018, are as follows:
Home Health
Probes Processed October 1, 2017 to September 30, 2018
|
Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – Sept. 30, 2018
|
Providers Compliant Completed/Removed from Edit
|
Providers Non-Compliant Progressing to TPE Probe 2
|
|
552
|
252
|
300
|
Findings by State
Palmetto GBA’s overview of results by state, for providers who have had edit effectiveness performed, for Probe 1 TPE review from October 1, 2017 to September 30, 2018.
|
State
|
Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – Sept. 30, 2018
|
Providers Compliant Completed/Removed from Edit
|
Providers Non-Compliant Progressing to TPE Probe 2
|
|
Arkansas
|
8
|
6
|
2
|
|
Indiana
|
15
|
7
|
8
|
|
Kentucky
|
7
|
3
|
4
|
|
North Carolina
|
9
|
4
|
5
|
|
New Mexico
|
2
|
0
|
2
|
|
Ohio
|
48
|
13
|
35
|
|
Oklahoma
|
24
|
12
|
12
|
|
Other
|
6
|
2
|
4
|
|
Tennessee
|
3
|
0
|
3
|
|
Texas
|
430
|
205
|
225
|
Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as: Minor: 0 - 20% and Major: 21 - 100%
Top 5 Denial Reasons October 1, 2017 to September 30, 2018
- 5FF2F/5TF2F — Face-to-Face Encounter Requirements Not Met
- 5F023/5T023 — No Plan of Care or Certification
- 5F072/5T072 — No Physician’s Order for Services or More than Ordered
- 5F070-5T070 — No Documentation of Services Rendered
- 5F301/5A301 — Information Provided Does Not Support the Medical Necessity for Therapy Services
Visit the full Palmetto GBA article on these results for more details on each of the top five reasons for denial, as well as Palmetto’s guidance on how to avoid each.
Thank you!