Partner and Vice President of Compliance  for DoctorsManagement
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This auditing and compliance “Tip of the Week” was originally published by the
National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Just when you thought things could not get more complicated or arduous with The CMS program, they find new and more laborious ways to wreak havoc on your organization / practice like the Targeted Probe and Educate (TPE) program. According to CMS, “the program itself is designed to help providers and suppliers reduce claim denials and appeals. TPE is intended to increase accuracy in very specific areas and the Medicare Administrative Contractors (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.”

However, just as we have been in the past, we are here for you now to ensure you have a game plan in place to ensure compliance and to come out of this process unscathed.

 If accuracy still does not improve after 3 rounds of education sessions, you will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.

Thus far, we have seen TPE focus on physician signatures as well as medical necessity. With regard to the signatures, we have seen everything from missing signature to refusal to accept signatures that are illegible or even those signed electronically. This one is a very simple solution:

  1. Ensure all notes are signed within 24 hours or as soon as possible after the encounters are completed. My personal recommendation is not to exceed 48 hours given that the majority of encounter and procedure notes are completed quickly due to being on an EMR. However, if notes are dictated and the turnaround is 48 hours, a signature should occur within 24 hours.
  2. If you have multiple providers within the group and there are signatures which could be considered illegible, submit a master signature log in addition to the requested documentation to thwart any effort by the MAC to refuse the service.
  3. Electronic Signatures are completely permissible per Medicare Program Integrity Manual, Chapter 3, Section (policies for Medicare signature requirements) of the specific section within the Medicare Claims Processing Manual that this can be confirmed. There is also a Signature Requirements Fact Sheet that can be found on CMS’ website. I believe this issue (#3) is a misinterpretation of the guidelines by some CMS reviewers and not a systematic problem at the MACs.

The second of the issues we have been dealing with for clients targeted under TPE is “Medical Necessity”. This one is a bit more daunting to deal with because it is not something that is measured or quantified. “Medical Necessity” is something that must be qualified and can only be done so by a “qualified” licensed medical professional with the requisite skills in the specialty they are auditing. “Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Auditors must defer to the Clinical Review Judgment of the providers, which involves two (2) steps:

  • The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient and,
  • The application of this clinical picture to the review criteria is to make a reviewer determination on whether the clinical requirements in the relevant policy have been met. MAC, CERT, RAC, and ZPIC/UPIC clinical review staff shall use clinical review judgment when making medical record review determinations about a claim.

It is also critical to know who is reviewing your claims and to emphasize my points above, CMS provides clear guidelines in Section of the Medicare Claims Processing Manual:

The MACs, CERT, and ZPIC/UPICs/UPICs shall ensure that medical record reviews for the purpose of making coverage determinations are performed by licensed nurses (RNs and LPNs) or physicians, unless this task is delegated to other licensed health care professionals. RACs and the SMRC shall ensure that the credentials of their reviewers are consistent with the requirements in their respective SOWs. During a medical record review, nurse and physician reviewers may call upon other health care professionals (e.g. dieticians or physician specialists) for advice. The MACs, CERT, and ZPICs/UPICs shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e. speech therapy claim, physical therapy). RACs and the SMRC shall follow guidance related to calling upon other healthcare professionals as outlined in their respective SOWs. RACs shall ensure that a licensed medical professional will perform medical record reviews for the purpose of determining medical necessity, using their clinical review judgment to evaluate medical record documentation. Certified coders will perform coding determinations. CERT and MACs are encouraged to make coding determinations by using certified coders. ZPIC/UPICs/UPICs have the discretion to make coding determinations using certified coders.

It should also be noted that if you disagree with the findings of an audit you have the right to request the auditor’s credentials that demonstrate compliance with the above section… with section of the MCPM is the section titled “Credential Files” and it states:

The MACs, CERT, RACs, and ZPIC/UPICs shall maintain a credentials file for each reviewer (including consultants, contract staff, subcontractors, and temporary staff) who performs medical record reviews. The credentials file shall contain at least a copy of the reviewer’s active professional license.

Get Your Game Plan On!
  1. You have to be aware of your coding patterns. If you do not have a risk program in place, you will find yourself at the mercy of the payers making determinations on what services they consider moderate or high risk and wondering if those services are truly at risk for having an aberrance or outlier status.
  2. Once you have identified those services posing a moderate or high risk to the organization create an audit sample. 
  3. Ensure you have the audits performed under attorney/client privilege whether conducted by in-house staff or an external vendor like DoctorsManagement, LLC.
  4. If overpayments are identified, depending on the amount and severity, your attorney will advise on the most effective process to follow for making refunds to Medicare following the 60-day rule.
  5. Finally, work with your attorney or compliance consultant on developing a Corrective Action Plan (CAP) and ensure there is proper auditing and monitoring on a go-forward basis to ensure compliance.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
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