![]() The contractor then pulls and examines between 20 and 40 of the organization’s claims and supporting medical documentation. When selected for a TPE, hospices receive a notification letter from their MAC. TPEs also focus on services that have high national error rates and represent a financial risk to Medicare, according to CMS. The TPE program is designed to identify providers that have frequent errors on their Medicare claims or billing practices that CMS considers to be unusual. Even prior to the pandemic, fewer than 50% of hospices indicated that they were ready for a federal audit or additional document request, according to a 2019 survey of 170 organizations by Optima Health.ĬMS briefly suspended most audit activity during summer 2020 at the height of the COVID-19 public health emergency, but now they are back in full swing.Īudits come in two varieties: Targeted Probe and Educate (TPE) audits conducted by Medicare Administrative Contractors (MACS) and others involving Unified Program Integrity Contractors (UPIC). ![]() Many hospice providers express uncertainty about their ability to weather an audit. “It then puts them under this levels of scrutiny that they can avoid if they take the extra time to really understand what is required by CMS and contractors.” If they see a pattern of errors, then their antenna goes way up, and it causes them to say,‘Okay, we’ve got a provider here that isn’t paying attention to the details that are important to the regulator,” Jon Rawlson, founder and president of Armory Hill Advocates, LLC., told Hospice News. “CMS auditors often look for every little error. In the aftermath of these investigations, hospices have found themselves under more intense scrutiny while navigating survey reform and enhanced oversight.Įven if auditors do not find deficiencies or violations, the audit process can be a very time-consuming and expensive process for providers, particularly in terms of personnel work hours. This impetus is coupled with investigative reports from OIG identifying both serious quality concerns and vulnerabilities in the system when it comes to billing and reimbursement.
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