CMS Targeted Probe & Educate (TPE)
The Centers for Medicare & Medicaid Services (CMS) utilizes Medicare Administrative Contractors (MAC) to perform select Medicare audits and to analyze clinical documentation for broad range of other Medicare claims under review. In 2014, CMS began a program - called "Probe and Educate" - that combined a review of a sample of Medicare claims with education in an effort to further reduce errors in the claims submission process. In October of 2017, CMS elected to move from a limited Probe and Educate program to a more nationally-focused one - Targeted Probe and Educate or "TPE".
When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE typically involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. "TPE" is intended to convey that the number of claims reviewed is relatively small in comparison with previous provider specific review where the number of claims reviewed for an individual provider may have been much larger. After each round, providers are offered individualized education based on the results of their reviews. This program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017. CMS decided to expand to all MAC jurisdictions later in 2017.
Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to another UPIC auditor / Recovery Auditor, or other action. Providers / suppliers may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates.
CMS continues to implement a wide range of anti-fraud initiatives that were originally introduced within the Affordable Care Act and the Small Business Jobs Act of 2010 (P.L.111-240). CMS is specifically focusing on a program integrity approach centered on prevention / detection, anti-fraud technologies and provider risk-based payments. The strategy currently leverages the nationwide Targeted Probe and Educate (TPE) audit program with a major focus on the ultimate goal - the UPIC audit program. CMS also relies heavily on working side-by-side with and supporting more integrated actions among law enforcement agencies, other governmental entities health care providers and third-party audit contractors (i.e. UPIC auditors).
The real issue? The vast majority of healthcare providers are good people that obey the law, avoid False Claims Act liabilities and make every effort to adhere to multiple layers of conflicting and seemingly arbitrary Medicare & Medicaid coverage criteria for payment. While third-party, publicly-traded UPIC audit contractors are building businesses and selling out to the highest bidder, providers are caught in a giant web of never-ending audits of their services. Hospitals, physicians, home health agencies, hospices, skilled nursing facilities, inpatient rehab facilities, physical therapists and HME suppliers.... all are facing daily challenges of operating under enormous governmental scrutiny and adhering to ever-changing CMS compliance requirements. Even some of the most detailed of coding issues (i.e. modifier 59, MS-DRGs, etc.) are now being pushed to the forefront by the OIG and other auditors to reinforce that it is not only about fraud, but containing the national Medicare & Medicaid budgets.
Now, more than ever, Medicare & Medicaid audit contractors are applying subjective opinions and inaccurate criteria in order to insure that they get the next RAC, TPE or UPIC audit contract. Great providers are being bankrupted and thousands of people are losing their jobs to unscrupulous auditors that are just trying to make a buck and increase their company's stock price.
Corporate Integrity Agreements
The Office of Inspector General (OIG) negotiates Corporate Integrity Agreements (CIA) with health care providers and other entities as part of settlements of arising from UPIC audits, Federal health care program investigations or under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, the OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other Federal health care programs. For providers that don't initially discover overpayment issues and self-disclose, CIAs are the ultimate "stick" used by the OIG to enhance the overall effectiveness of provider compliance programs. Today, there are over 400 provider organizations and 2,000+ covered entities living under active Corporate Integrity Agreements across the U.S.
Driven by UPIC audit outcomes (as well a wide range of other CMS audit programs and federal investigations), providers facing CIAs enforced by the OIG live in constant scrutiny and the ongoing costs to the organization are extraordinary. Yes, the provider is able to stay in business in the short-term, but the long-term cost (many times including forced bankruptcy) of non-compliance far out-weighs the cost of upfront cost of implementing and maintaining a zero-risk compliance environment. CIAs have many common elements, but each one addresses the specific facts at issue. As UPIC audits continue their rollout cost-to-coast, CIAs are an ever-increasing risk for all provider types – hospitals, physicians, home health agencies, hospices, SNFs, IRFs, pharmaceutical suppliers, DME companies, etc. A comprehensive CIA typically lasts 5 years and includes costly requirements such as:
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Unified Program Integrity Contractors (UPIC Audits)
The inevitable next step… CMS is developing a Unified Program Integrity Contractor (UPIC audits) strategy that restructures and consolidates the current Medicare and Medicaid integrity audit programs. Ultimately, this consolidated audit strategy appears designed to reduce decentralization of CMS program integrity initiatives (i.e. TPE audits, ZPIC audits, MAC audits, RAC audits, etc.) and move forward with a more centralized, high-tech structure.
Historically, the Medicare & Medicaid audit landscape belonged to RAC auditors (i.e. Cotiviti, etc.), ZPIC auditors, Office of Inspector General, MACs and a host of other law enforcement agencies. Tomorrow (and for the long-term), it becomes the domain of contracted UPIC auditors. For providers, facing a UPIC audit defense can be life changing. Losing UPIC appeals can be financially devastating. UPIC auditors will use technology-driven data-mining & business logic, determine the audit focus areas, choose their targets and set the rules. It's a zero-sum game with the deck stacked against providers to insure the outcome falls the UPIC auditor's way.
CMS Coverage Criteria - RAC, TPE & UPIC Audits
Time and time again, the U.S. courts have held that Medicare coverage criteria rules-the-day in the evaluation and determination of payments for Medicare services. While each state has also introduced specific coverage criteria for their Medicaid beneficiaries, the judicial concept that this criteria governs Medicaid payments holds true. The courts have long-determined that BOTH providers and CMS auditors must use codified CMS coverage criteria to support beneficiary payments. Whether it is a RAC auditor, UPIC auditor or MAC completing a TPE audit review, outcomes of a RAC audit, UPIC audit or TPE audit MUST be based on this criteria and may not be based on the subjective opinion or self-determination of the CMS auditor.
Below is a list of some of the most commonly referenced "national" Medicare coverage criteria that should be used as the basis for decisions by either UPIC auditors or TPE audit reviewers (the MAC). In addition to these national references, each geographic region may be governed by Medicare coverage criteria established by their regional Medicare Administrative Contractor or "MAC". These more regional or local coverage criteria can be changed / updated frequently by the MAC and are critical to providers that are facing RAC, TPE or UPIC audits. [*important note: there are also 1,000s of additional, discrete coverage criteria that can also govern provider payments (i.e. OCE/CCI edits, HCPCS / CPT code definitions, etc.)]:
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Trends Matter (Medicare UPIC Appeals)
Medicare ALJ hearings have always been considered the provider's best chance to get a fair and independent review of their denied claims. OMHA hearings (the ALJ's office) are consistently handled efficiently & professionally. Through about 2007, most providers were in front of the judge within 90 to 120 days. ALJs were given the time to thoughtfully weigh a wide-range of issues (i.e. medical necessity, physician opinion, Medicare coverage criteria, etc.) and providers typically won over 75% of all cases.
However, by 2017 the landscape had changed dramatically. With the expansion of TPE and the proliferation of UPIC audits, RAC audits, ZPIC audits and other programs, OMHA was buried under millions of denied claims. Just setting a ALJ hearing date went from 90 days to over 3 years in many UPIC audit appeal cases. ALJs were required to focus solely on Medicare coverage criteria and pushed to "clear the decks" and move on to the next case. In the next section, we discuss the importance of Medicare / Medicaid coverage criteria and the impact that it has on today's CMS appeals.
$150M+ UPIC Denials Recovered For Providers
Medicare Benefit Policy Manual - Chapter 11 (ESRD Services)
Medicare Claims Processing Manual - Chapter 1 (General Billing)
Medicare Claims Processing Manual - Chapter 3 (Inpatient Hospital)
Medicare Claims Processing Manual - Chapter 4 (Outpatient Hospital)
Medicare Claims Processing Manual - Chapter 5 (Outpatient Rehab)
Medicare Claims Processing Manual - Chapter 6 (SNF)
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CMS Takes Aim
The target? Everyone. In addition to having thousands of individual auditors under the Centers for Medicare and Medicaid Services (CMS) umbrella, the government is now utilizing leading-edge database technology and integrated business logic to assist in the day-to-day review of millions of electronic Medicare & Medicaid claims for payment. Providers can no longer fly under the radar of the UPIC, TPE or RAC audit process. If you submit electronic claims to CMS for payment, you are instantly being “audited” for the services rendered. Whether it's a pre-pay or post-pay UPIC audit, the nation's best providers and being caught-up in a very frustrating, challenging and costly audit process.
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Jackson Davis HealthCare, Inc. is the provider's #1 source for winning Medicare & Medicaid audit appeals and zero-risk compliance solutions. UPIC appeals, TPE appeals, RAC appeals and the nation's BEST compliance services. We are the go-to resource for providers nationwide for UPIC audit defense, TPE audit defense, RAC audit defense, RESTORE Program Integrity services, medical staff compliance education, clinical documentation improvement, transaction due diligence audits, periodic internal audits and integrated CMS compliance solutions.
Over the past 30 years, Jackson Davis professionals have assisted healthcare providers nationwide in building winning appeals for 10,000+ Medicare and Medicaid cases. We work side-by-side with integrated health systems, physician practices, skilled nursing facilities, hospices, home health agencies, inpatient rehabilitation facilities, DME suppliers and physical therapists to insure CMS compliance and win Medicare & Medicaid appeals. UPIC audits, TPE audits, OIG audits, USAO audits, Medicare audit extrapolations, defending against CMS fraud allegations, transaction due diligence and a wide range of proactive CMS compliance services - we are in your corner and we prove it every day.
Hospice Coverage Criteria - UPIC Auditors.... Getting It Right?
Depending on where the hospice provider is located, each of the 3 designated HHH Medicare Administrative Contractors (MACs) have taken different approaches to the use of evidence-based outcomes for the development of their respective Hospice Local Coverage Determinations (LCDs). However, the UPIC auditors - as well as the QIOs (Maximus and C2C) - continue to inappropriately apply this criteria for both UPIC audits and Medicare appeals. The result? Hospices nationwide are being forced to appeal inappropriately denied cases through the administrative process in an all-out effort to get relief from OMHA ALJs or the Medicare Appeals Council.
First, let's briefly review the hospice regions and applicable LCDs. Then, we'll try to cover the most prevalent - and incorrect - application of the adopted hospice coverage criteria for the certification of terminal illness.
The HHH regions: (1) CGS [Colorado, District of Columbia, Delaware, Iowa, Kansas, Maryland, Missouri, Montana, North Dakota, Nebraska, Pennsylvania, South Dakota, Utah, Virginia, West Virginia]; (2) NGS [Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, New Jersey, Nevada, New York, Oregon, Puerto Rico]; and (3) Palmetto GBA [Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, New Mexico, Ohio,
Oklahoma, South Carolina, Tennessee, Texas].
The LCDs: (1) CGS has a single, consolidated LCD that covers the full range of hospice primary diagnoses - Hospice Determining Terminal Status (L345380); and (2) NGS also has a single, consolidated LCD that covers the full range of hospice primary diagnoses and mirrors the CGS LCD - Hospice Determining Terminal Status (L33393). The LCDs for (3) Palmetto GBA are divided into a series of 7 discrete LCDs that individually cover the most common hospice primary diagnoses (excluding cancer) - Alzheimer's Disease & Related Disorders (L34567), Cardiopulmonary Conditions (L34548), Adult Failure To Thrive Syndrome (L34558), Neurological Conditions (L34547), Liver Disease (L34544), HIV Disease (L34566) and Renal Care (L34559).