Knowledge Base Article

As part of the Targeted and Probe and Educate (TPE) Process, Palmetto GBA hosts Quarterly Medical Review Hot Topic TPE Teleconferences. These sessions are open to all providers. The most recent Jurisdiction J (JJ) teleconference was on June 3, 2019. Questions and Answers (Q&A’s) from this session are now available on the Palmetto GBA JJ website.

Before opening the session up to questions, Palmetto reminded providers that the interaction between the Palmetto GBA reviewer and your hospital is a key component of the TPE model and “to ensure that the reviewer can reach out to the individual in your organization who can benefit from the educational contacts that we’re making, we do want to remind and encourage you to submit the name and phone number of that designate in your organization when you respond to the additional documentation request.”

Below are just a few of the Q&A’s from the teleconference where the MMP team has been asked similar questions from our clients.

Question: We are in TPE review and received claim denials, but haven’t received a letter yet. Should we wait until the reviewer calls before submitting an appeal?

Answer: The appeal process has not changed. You are notified of appeal rights the date you receive the electronic remittance advice of the finalized claim. You have 120 days to request an appeal from the denial date, which is the date of the remittance advice. Therefore, you should not wait until the TPE review letter and subsequent education call.

Question: How many ADRs are requested from a facility? If we have 35 patients and we receive 30 ADRs, is that normal?

Answer: The TPE model is set so that a sample of between 20 and 40 claims are requested to be reviewed per provider. The number of claims chosen is based on the denial rate associated with that service or the probability of claims being sampled improperly. This is all taken into account prior to setting the edit and we usually sample low for most providers. If the service error rate or probability of improper payment for that service is very high; we’ll sample high. Without knowing the exact service and all other information associated with your edit, then 30 claims is a normal sample size.

Question: It seem like the ADRs are sporadic, is there a length of time it takes for each sampling?

Answer: It is dependent upon the provider and claim submission. If you have a higher volume of a certain type of claim, we are able to sample faster. If the other services are provided at a lower frequency; then it is a more sporadic build and it will take longer to meet the 20–40 claim sample.

Question: Is there an overall error rate to determine whether we need to proceed to the next round?

Answer: We wait until the reviews are final before making those decisions. What we're looking for is a claim denial rate or charge denial rate — either one that is greater than 20 percent. If 20 percent or more of your claims are denied; then we are going to progress you. If 20 percent or more of your total charges are denied for the entire sample, then we will progress you to the next round.”

In a related CMS TPE Q&A's document, they answer the question of what is the error percentage that qualifies as a “high denial rate?” CMS’ responded that “the error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process.”

I encourage you to read the complete Q&A document as it provides additional useful information such as where to find the list of active TPE medical review topics. Also, Palmetto GBA has two more teleconferences planned for 2019, September 3rd and December 2nd. For those interested in listening in, you can visit the Palmetto GBA Event Registration Portal TPE Teleconference Schedule webpage.