Targeted Probe and Educate Progress Update: Hospice - Beneficiary Sharing

Published 03/10/2020

Targeted Probe and Educate Progress Update: Hospice - Beneficiary Sharing
The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides Probe 1 TPE results statistics from October 1, 2017 to January 31, 2020.

Findings
Medical Review initiated Probe review edits for providers identified through data analysis demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the Probe 1 TPE review. Current Probe 1 Hospice Beneficiary Sharing Results are as follows:

Beneficiary Sharing
Probes Processed October 1, 2017 – January 31, 2020

Number of Providers with Edit Effectiveness PerformedProviders Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Removed for Other ReasonsOverall Charge Denial Rate

4

4

0

0

2%

Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as:

Risk CategoryError Rate

Minor

0–20%

Major

21–100%

 

Hospice Beneficiary Sharing

Top Denial Reasons October 1, 2017 — January 31, 2020

  1. 5FFIP/5CFIP — Invalid Plan of Care
  2. 5TH99 — Billing Error
  3. 5FNER/5CNER — The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements

5FNER/5CNER — The Hospice Election Statement Does Not Meet Statutory/Regulatory Requirements

Reason for Denial
The Hospice Election Statement did not include the effective date of the election. Statutory/regulatory requirements were not met. 

How to Avoid a Denial
A Medicare beneficiary must complete an election statement before the Hospice Medicare Benefit can begin. The election statement must include the following items of information:

  • Identification of the particular hospice that will provide care to the individual
  • The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
  • The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
  • The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive
  • The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or nurse practitioner (NP) was designated as the attending physician. This information should include, but is not limited to, the attending physician’s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician.
  • The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice
  • The signature of the individual or representative

5FFIP/5CFIP — Invalid Plan of Care

Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not include a valid plan of care for all or some of the dates billed.

For a beneficiary to receive hospice care covered by Medicare, a plan of care (POC) must be established before services are provided. The POC is developed from the initial assessment and comprehensive assessment and services provided must be consistent with the POC.

How to Avoid a Denial

  • The POC must contain certain information to be considered valid. This includes:
    • Scope and frequency of services to meet the beneficiary's/family's needs
    • Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief
    • Services that are reasonable and necessary for the palliation and management of the beneficiary's terminal illness and related conditions
  • The plan of care must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every fifteen (15) calendar days

5TH99 — Billing Error

Reason for Denial
The services billed were not covered because the charges were billed in error.

How to Avoid a Denial

  • Ensure accuracy of billing prior to submitting the claim(s) to Medicare
  • Submit a corrected UB92 with an 817 or 827 bill type when billing errors are discovered by the hospice agency. If the claim has been selected for medical review, submit the hardcopy corrected UB92 with the records to Palmetto GBA.

Education
Providers are offered an individualized education session where each claim denial will be discussed, and any questions will be answered. Palmetto GBA offers a variety of methods for provider education such as webinar sessions, web-based presentations and teleconferences. Other education methods may also be available.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 2 will advance to Probe 3 of TPE at least 45 days from completion of the 1:1 post probe education call date. Palmetto GBA offers education at any time for providers. Providers do not have to be identified for TPE to request education.

References