How to Survive a CMS TPE Audit
It’s Coming: Here’s How to be Prepared
Kaye Moseley, Technologist Representative - E: firstname.lastname@example.org
For many years providers of hyperbaric medicine have wondered what they would do if they were ever audited by the Centers for Medicare and Medicaid Services. They don’t have to wonder about that now: No longer is if IF they get audited by CMS but WHEN.
You may remember that in 2015 CMS did a trial of Prior Authorization for non-emergent hyperbaric oxygen treatments in the state of Illinois, Michigan and New Jersey.
When that project ended in February of 2018, the results of the audit were evaluated by an independent agency and internally by CMS. Just the first year alone saved Medicare approximately $5.33 million in non-emergent requests – in other words, in about a 50% denial rate.
This brings us to the much-dreaded Targeted Probe and Educate (TPE) Audit for prepayment of HBO2 claims. The Medicare Administrative Contractor (MAC) for your region uses data analysis to identify providers and suppliers who have high claim error rates; or those with unusual billing practices and items and services with high national error rates. Both are a financial risk to Medicare. As an example, Novitas Solutions, the MAC for Texas, can trigger a TPE audit if the Provider/Supplier is billing more than 10 claims per month. For providers and suppliers who are compliant with Medicare policies the chances of being chosen for a TPE audit are lower.
What triggers an audit?
You may be wondering what errors could trigger a TPE audit. Some of the most common errors include:
- No provider signatures on documents;
- Lack of supporting documentation to meet medical necessity;
- Missing referrals, encounter notes do not support all elements of eligibility, missing HBO2;
- Descent time, ascent time, total time of treatment, the gas used in the treatment was used (hard-sided); and
- Missing HBO2 order(s) for each day of treatment.
Know the local coverage determination for your region.
Create a checklist for each condition you treat with HBO2 that addresses all documentation requirements that support medical necessity for those conditions. Omitting only one of the requirements could give the MAC reason to deny the claim. Remember, there was a 50% denial rate in the prior authorization for non-emergent HBO2 conditions trial in only three states. Can you survive on a 50% denial rate?
The process for TPE audits is straightforward. The MAC for your region will send the provider/supplier a letter stating they have been selected for a TPE audit and will be sending an ADR (Additional Documentation Request) for 20 to 40 medical records within a certain time frame. This is a pre-audit letter and requires no action by the provider/supplier at the time of receiving this letter. Once the ADRs start to arrive there will be one for each patient selected by the MAC, with the dates of service they are requesting and the total charges for those dates of service. The ADR will be very specific as to the documents the MAC wants the provider/supplier to send within 45 days of receiving the ADR. They are:
- Signed provider order;
- Advance beneficiary notice if issued;
- History of present illness to include clinical documentation of diagnosis; symptoms supporting the medical necessity of services (including, if applicable, wound grade classification per Wagner scale);
- HBO2 treatment progress notes (including measurable signs of healing);
- HBO2 treatment logs with documented length of treatment time;
- Results of all testing for the services billed;
- Documentation of Provider attendance and supervision of HBO2 treatment;
- Itemized bill.
If the requested documentation is not received within the 45-day period, the claim will be denied due to lack of documentation which will contribute to the provider/supplier error rate. In addition, if the provider/supplier does not respond to the additional documentation request the MACs have the option to refer to the recovery audit contractor (RAC) or zone program integrity contractor (ZPIC)/unified program integrity contractor (UPIC).
The MAC has 30 days to review all the provider/supplier claims and provide the specific findings of the audit. If errors are found in the provider/supplier documentation, the provider/supplier will have 45 days to make changes and improve the area(s) of deficiency. If CMS finds there are still deficiencies in documentation, each provider/supplier will be invited to a one-on-one education session with a MAC representative. This process will be repeated three times. The goal of the Targeted Probe and Educate program is to help the provider/supplier increase accuracy in very specific areas, reduce claim denials and appeals by providing one-on-one education. If after three rounds of these one-on-one education sessions, the provider/supplier will be referred to CMS for more serious actions. No one wants to have that happen!
When involved in a TPE audit:
- Don’t panic.
- The provider/supplier should read the letter announcing the TPE audit very carefully and follow all instructions. The letter will provide the list of patient records and dates of service being requested, and it will be very specific on how to proceed.
- DO NOT send any records until the ADR is received. If records are sent to MAC before receiving the ADR, the MAC can deny the claims, and those denials will go against the provider/supplier’s error rate and possibly trigger more audits.
- Designate one point-of-contact person who will be responsible for gathering all documentation requested and will correspond with the MAC.
- If you are working for a management company, make sure you know who at the host facility handles requests for ADRs and offer to assist them in any gathering of documents to be sent to the MAC. Send only the documentation requested.
- Keep in mind the HBO2 evaluation, order for HBO2 treatment and she wound assessment may be in the medical record BEFORE the dates of service requested. Make sure the provider/supplier sends those documents as well. Without those documents the claim will be denied and will negatively affect the provider/supplier’s error rate.
- Include all radiology reports, lab results, other provider consultation notes, surgical reports, etc.
- DO NOT violate the 45-day window for submitting the requested documents; this, too, will have a negative effect on the provider/supplier error rate.
- DO NOT call the MAC for results of the audit – wait patiently.
- Don’t expect a lot of feedback from the MAC on the results. The MAC will send a letter saying either that the documentation was lacking and you are going to be involved in a second round of TPE audits, or they will say their findings were sufficient and you will not be moving on to the second round of audits. If you do not go to round two of the audits you will not be audited for at least one year.
I know from experience TPE audits can be daunting. The checklists I mentioned earlier – those based on the LCD documentation requirements – will be your best friend. I guarantee you will be happy you created them (I was). If you choose to stick your head in the sand and hope you won’t get audited, you might want to rethink that strategy.