We all know or should know by now that CMS and its contractors are very active in today’s home health and hospice provider environment in conducting pre-payment and post-payment review of Medical Records to support Medicare Conditions of Payment. Our staff is currently working with various entities involved with Targeted Probe & Educate (TPE), Unified Program Integrity (UPIC), Comprehensive Error Rate Testing (CERT) and Supplemental Medical Review Contractor (SMRC) audits. Documentation of services to support billing remains the number one risk area for providers. Palmetto GBA just released an update showing that 1605 home health providers have been reviewed for TPE. Of that number 694 (44%) were found to be compliant, 864 (56%) failed round one and were moved to round 2, 11 have been removed from the process for other reasons and 36 have already proceeded into round 3. The top denial reasons continue to be 1) F2F Requirements not met, 2) No Plan of Care or Certification, 3) No documentation of services rendered, 4) No physician order for services or more than ordered and 5) documentation insufficient to support skilled services billed or that services were reasonable and necessary. Many times, we are providing support for providers at the point that they already know they have failed TPE round 1. Our experience indicates best practice for providers is to involve your consultant to prepare for TPE as soon as you receive the notification. Pre-emptive steps can be taken to help prepare medical record submissions to your MAC Contractor initially and could lead to the best opportunity to pass the review. Between TPE and Review Choice Demonstration (RC) active in Illinois and soon in Ohio CMS believes they have better tools in place to identify billing errors and recover monies for the Medicare Trust Fund. Be prepared. S.M.A.R.T. (Strategies in Medicare Advisement Reimbursement and Training) works with the provider community to prepare, respond and to appeal negative results of the various medical review audit processes and also offers outsource OASIS / Coding reviews for home health agencies and quality assurance / coding services for hospice companies (see www.smarthcr.com).

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