The PDPM payment system doesn’t affect Part B therapy, but Part B claims are still eligible for auditing.
The implementation of the new PDPM payment system has dramatically changed the way facilities look at therapy. Even though the PDPM payment system doesn’t affect Part B therapy, CMS has targeted those Part B claims for auditing.
One area of concern is the TPE (Targeted Probe and Educate) audit completed by CMS/MACs for Part B claims. These types of audits are designed to help providers and suppliers reduce claim denials by increasing claim accuracy in very specific areas and appeals through one-on-one help. The goal is to help the facilities identify errors and correct them. Many common errors are simple errors. MACs use data analysis to identify providers and suppliers who have high claim error rates or unusual billing practices, and items and services that have high national error rates and are a financial risk to Medicare. Providers whose claims are compliant with Medicare policy won't be chosen for TPE.
Other items that can trigger a TPE audit includes missing physicians' signatures and missing or incomplete initial certifications/re-certifications. If chosen for a TPE audit you will receive a letter from your MAC and the MAC will review 20 to 40 of your claims and supporting medical records. You will be given at least a 45-day period to make changes and improve. If claims are denied the facility will be invited to a one-on-one education session. After one year of compliance the facility will not be reviewed again for at least one year on the selected topic unless significant changes in provider billing are detected. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.
Polaris consultants have shared some insight into facility TPE audit reviews. One major finding includes therapy minutes compared to units billed daily on the claim. According one facility's results the minutes did not correlate with the units billed which pushed the facility over the error rate for the first round of TPE audits and now the facility will continue into a second round of TPE audits. The facility was targeted in the TPE audit for an increase in therapy units identified in future claims submissions. This is yet another reason why it is important to understand that the claim going to Medicare must have accurate information, since it is the first record for Medicare review.
To prevent this type of audit the facility should be completing triple check not only on the Medicare Part A claims but the Medicare Part B claims. Due diligence is part of producing a clean claim prior to submitting the claim to Medicare. Polaris can assist with providing that due diligence by assisting facilities with an outside audit perspective.