What Home Health Providers Need To Know About The Medicare TPE Audit Process
Home Health Care News | By Joyce Famakinwa
There are decades-old home health providers that have not yet gone through the Medicare Targeted Probe and Educate (TPE) process. But all home health leaders should familiarize themselves with the review process and its potential outcomes, as well as its challenges.
That’s one key takeaway from a recent Home Health Care News webinar that was sponsored and presented by MatrixCare.
Broadly, TPE is a medical review program that began for the home health and hospice settings in December 2017. The goal of the program is to weed out improper payments by zeroing-in on providers with high claims denial rates or unusual billing practices.
The program was put on hold in March 2020, in accordance with the public health emergency. It was then reestablished in September 2021.
TPE has three pillars. Target refers to errors or mistakes that are identified through data in comparison to providers or peers.
Probe is the examination of 20 to 40 claims. The claim size is meant to be large enough to get a clear picture of the behavior without intending to be burdensome, Rachael Feeback, senior product manager at MatrixCare, noted during the presentation.
Education means helping providers reduce claim denials and appeals through one-on-one individualized education.
Some common claim errors include things like a missing signature of the certifying physician, documentation not meeting medical necessity and missing or incomplete certifications or recertification documents.
When a provider becomes the subject of a TPE audit, they receive a letter explaining the process. Then a Medicare Administrative Contractor (MAC) reviews between 20 to 40 of their claims and supporting medical records. If the audit finds discrepancies, after education occurs, the provider has 45 days to fix these issues. After this, the process begins again.
“If you fail three rounds, you could be referred to the OIG or CMS, you could even be facing a UPIC or a SMRC audit,” Feeback said. “It’s really important that you have a good process here.”…
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CMS Readies Providers for Interoperability and Prior Authorization Rule
McKnight’s Home Care | By Adam Healy
The Centers for Medicare & Medicaid Services offered providers resources to help prepare for the newly finalized Interoperability and Prior Authorization final rule, which will go into effect in 2026.
“In this rule, we explore ways that technology can improve and streamline the complex process of prior authorization,” Alexandra Mugge, deputy chief health informatics officer and director of CMS’ health informatics and interoperability group, said during a webinar last week. “By improving prior authorization processes for providers, we hope that they will be able to put that time back into taking care of their patients. So this would have a direct impact on the provider and saving time, but hopefully they can put that time into patient care, which will have a significant impact on the patient, as well.”
The rule is primarily focused on streamlining healthcare data sharing by using specialized application programming interfaces (APIs), tools that allow programs or applications to communicate with each other, Mugge explained. CMS’ rule will create multiple APIs for patients, providers and payers, which would “greatly improve data sharing and access to information” among these parties, she said.
Home care and hospice providers have generally not benefited from interoperable health data technology and, as a result, lack critical information about their patients. A specialized “Provider Access API” finalized in CMS’ rule would give all providers the ability to see their patients’ claims and encounter data, as well as their prior authorization information, another key focus of the rule.
“Automation and technological solutions are never enough to address a complex process like prior authorization,” Mugge said. “To truly look at prior authorization reform, we have also looked at … cultural changes that will help to support streamlining these processes in the future, in addition to the technology solutions.”
These changes include reduced prior authorization decision timelines and a requirement that payers provide a specific reason for denials, according to the rule. Specifically, the rule requires certain payers — such as MA, Medicaid and Medicaid managed care plans — to make prior authorization decisions within 72 hours for expedited requests, and within one week for standard, non-urgent requests.
Meanwhile, some critics have called on CMS to reduce decision timelines even further. The Improving Seniors’ Timely Access to Care Act, which has been endorsed by LeadingAge, would require Medicare Advantage plans to make prior authorization decisions within 72 hours of a request. |
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Developing a Cooperative Relationship Between Nursing Facilities and Hospice
By Barbara Karnes, RN
For many people, nursing facilities have become their home. It is therefore reasonable that Hospice services be available in facilities. BUT care in a facility is not the same as care in the home. Here are some of the differences—and challenges.
Nursing facilities’ focus, by regulations, is to keep people alive. All the care is concentrated on living the best possible life under the circumstances. Yet, most people in nursing facilities are there because of health challenges or aging that has made independent living unsafe. These people will die in the facility. I know that sounds harsh, but it is true. This is problematic because facilities are not trained in end of life. They are trained to keep life going.
Do you see where I am going with this? Nursing facilities and hospice go together but are also at odds with each other.
Here are my thoughts on developing a cooperative relationship between the facility, the patient and the patient’s family.
One hospice team is assigned to a specific facility. This team (nurse, home health aid, social worker, chaplain) becomes a set of familiar faces and provides consistency.
The team provides ongoing inservices to the entire facility staff. These inservices should include information on the signs of approaching death, end of life nutrition, what to do as death approaches, how to talk with family members, and when to begin hospice services.
When a hospice team member arrives, they should first check in with the staff. They should say their hellos, be friendly and talkative, and ask about patients. They should then check the medical records of the patients to be seen and read the notes since the last visit. Ask about the patient’s family, their visits, and their concerns. Finally, the hospice team member can see the patient. Sit by the bed, use gentle touch if it is appropriate, begin talking about the day, and ask how they are doing and feeling. Become a friend as well as a professional, all the while assessing.
The team member will chart the visit and report their assessment to the staff nurse before leaving.
Call, that day, the patient’s primary family contact and report your visit and assessment. The family is as much your responsibility as the patient.
To summarize:
* Have the same hospice team for each individual facility.
* Provide inservice to the facility staff on a regular basis. Be part of new employee orientation.
* Make yourself known among the staff. You want them to know you, and to trust you and your knowledge.
* On a routine patient visit: First talk with the staff, get an update on the patient's condition, progress, and activity. Check the patient’s chart. Then spend time with the patient. Sit, assess, visit. Return to nursing staff and report your assessment, answer questions. Contact the primary family member and report your assessment.
Consider the nursing facility as part of the hospice team, but also as family. They are as much caregivers as the family is in a private home. They have feelings, attachments, and concerns. They are part of our hospice care also. |
The Operational Advantages Of Hiring Seniors To Provide Home Care
Home Health Care News | By Joyce Famkinwa
Seniors Helping Seniors has long distinguished itself from other home care companies by hiring active seniors to serve as caregivers. Josh Obeiter — an owner of one of the company’s franchise locations — has seen even more added value from this strategy as the industry at large combats labor shortages.
At Seniors Helping Seniors, the average age of an employee is around 70 years old, and 80% of caregivers are in their 60s and 70s, according to Obeiter.
“People often have a lot of resistance when their family members say, ‘I think it’s time to bring in a caregiver, you need help,’ especially when there’s cognitive impairment,” he told Home Health Care News. “People lack the insight into their own deficits, so our model of having somebody who looks and feels more like a friend or neighbor allows the person receiving the help to feel a lot more comfortable and typically a lot more receptive.”
Pennsylvania-based Seniors Helping Seniors is a personal care franchise company that has over 200 locations in 36 states.
Obeiter owns and operates a Seniors Helping Seniors in the Greater Boston area. This location offers non-medical home care with a focus on providing care to seniors living with Alzheimer’s and other dementias. It serves over 200 clients and employs more than 200 caregivers.
Through Seniors Helping Seniors Boston, Obeiter has employed more than 1,000 seniors. Over the years, he has seen the benefits of tapping into this underutilized labor pool.
Since the majority of caregivers at Senior Helping Seniors are retirees, the company doesn’t have as many employees who are juggling multiple jobs across different home care agencies.
“They’re not straddling between Senior Helping Seniors and another non-medical home care agency, or an assisted living,” Obeiter said. “They’re able to come to us looking for part-time work. We’re able to fill what they’re looking for, so they don’t need to go elsewhere for work.”
Employees who aren’t juggling multiple jobs are able to bring their full energy to caregiving, Obeiter noted.
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