The “Vacation” Is Over: CMS Resumes Hospice Targeted Probe and Educate Audits

On September 1, 2021, as hospice providers continue to grapple with the demands of the ongoing pandemic, the Centers for Medicare & Medicaid Services (CMS) ended its temporary suspension of the Targeted Probe and Educate (TPE) audits, which were placed on hold during the early days of the COVID-19 Public Health Emergency in order to ease the burden on healthcare providers.

For providers requiring a refresher, the TPE audit program essentially remains unchanged. Medicare Administrative Contractors (MACs) will identify providers for audit based on data analysis. Targets for audit will be individual providers or suppliers with high claim error rates or unusual billing practices, often related to categories of items or services with high national error rates which CMS has deemed as posing a financial risk to the Medicare trust fund. Providers selected for a TPE audit will receive a notification letter from their MAC alerting them to submit medical records and related supporting documentation for 20 to 40 claims. TPE audits could potentially continue until a provider’s accuracy rate improves, for up to three rounds of audits (consisting of 20 to 40 claims each round). After three rounds of audits, providers that continue to have a high error percentage are referred to CMS for further action.

If issues are identified by the MAC during the TPE audit, providers are given at least 45 days to address any deficiencies and submit corrections as needed. The MAC will also offer to provide a one-on-one education session via teleconference or webinar to address any issues identified during the audit, particularly when claims are denied. Hospice providers that have no issues identified or who have “passed” the TPE process with a low enough error rate will be released from further TPE review and will not be reviewed again for the same issue for at least one year.

Providers should also be aware that any claim denials from these TPE audits may be appealed through the standard Medicare administrative appeals process. If claim denials are overturned through appeal, the revised error rate as a result of the appeal will be taken into consideration for subsequent TPE audit rounds or by CMS, if the provider has been referred to CMS for additional action. If you have any questions about preparing for a TPE audit, addressing any claim denials with the MAC, or navigating the Medicare administrative appeal process, please contact Lanchi N. Bombalier for further information.