Don't gamble on your claims, van Halem Group says

LAS VEGAS - Although Medicare is attempting to reduce claim denials and appeals with a “friendlier” process, HME providers still need to take that process seriously.

Originally launched as a pilot program in one MAC jurisdiction in 2016, the Targeted Probe and Educate program was expanded to all jurisdictions in October 2017.

“Reducing the provider burden is great—who doesn't want to reduce burdens,” said Wayne van Halem, president of The van Halem Group, during his Medtrade Spring session, “Migrating from Widespread to Provider Specific Reviews.”  “But it has some serious impact on providers if it goes the wrong way.”

 Once a provider has been selected for TPE, they will be notified by a letter from their MAC. The MAC will review 20 to 40 claims and supporting medical records, and, if enough claims don't pass, the provider can receive one-on-one education and given 45 days to make improvements and go through another review.

If the provider doesn't show improved error rates after three reviews, they will be referred to CMS, which could refer the provider for a more aggressive ZPIC/UPIC audit or revoke their billing number, said Kelly Grahovac, senior consultant with The van Halem Group.

“”The goal of education is to take their recommendations and apply them to your practice,” she said. “They want to see that you are working to make it better.”

The most common errors: records not citing the need for specific equipment; the equipment is not medically necessary; and the detailed written order is missing the provider's NPI number or has illegible or missing signatures, said Grahovac.

“Signatures are the easiest thing for your reviewer to deny,” she said. “If they can't see it, they are done. Don't gamble. Consider every claim is going to be audited—cross your t's and dot your i's.”