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Comparison of KEPRO (QIO) and Targeted Probe and Educate (TPE) Processes

The different requirements are compared and contrasted here by Mary Bourland, M.D., vice president of medical documentation at Mercy in St. Louis, Missouri. Contact her at mary.bourland@mercy.net.

KEPROTPE Process - Hospital BillingTPE Process - Physician BillingTPE Process Challenges/Burden
Initial NotificationOne designated locationHospital able to designate location
  • Providers

  • Receipt of initial notification often unknown

Inability to identify notices and respond timely
Request for RecordsSingle letter requesting ALL records for designated review
  • Records (ADR) requested individually by mail

  • Nebulous identification of total population of record for audit

  • Can track individual requests on eSolutions

  • Records (ADR) requested individually by mail

  • Nebulous identification of total population of record for audit

  • No electronic reference such as eSolutions to ensure we are receiving all PB Requests.

  • Deadlines for response on individual claims included in same audit differ

  • Results in excessive burden to provider’s attempts to respond

Provision of RecordsMail or fax option - typically too large to fax
  • Electronic portal

  • Novitas portal size adequate for uploading entire record

  • WPS portal size typically is not large enough to support large records - results in some denials with MAC indicating they did not receive entire record.

  • Electronic portal

  • Novitas portal size adequate for uploading entire record

  • WPS portal size typically is not large enough to support large records - results in some denials with MAC indicating they did not receive entire record.

Cost, accuracy, and timeliness of record submission
Chart SelectionNot applicableDifferent auditors on single patient with recurrent encounters selected under one plan of care - e.g., HBOT series accounts for the same patient.Different auditors on single patient with recurrent encounters selected under one plan of care - e.g., HBOT series accounts for the same patient.Physician dissatisfaction and loss of credibility of TPE program
CriteriaDefined, published, and updated criteria
  • Auditing criteria not always available.

  • When NCD/LCD available often vague and subject to interpretation.

  • Criteria and auditing logic often not clearly provided in education session.

  • Auditing criteria not always available.

  • When NCD/LCD available often vague and subject to interpretation.

  • Criteria and auditing logic often not clearly provided in education session.

Physician frustration, increased documentation burden, unclear expectations
Auditor KnowledgeTrained Physicians (thoroughly understand criteria and application) audit and educate
  • Rarely physicians to audit

  • Nurse Auditors are not always knowledgeable in either clinical guidelines, NCD/LCD interpretation, coding guidelines or all of the above.

  • Rarely physicians to audit

  • Nurse Auditors are not always knowledgeable in either clinical guidelines, NCD/LCD interpretation, coding guidelines or all of the above.

Loss of credibility of TPE program, physician dissatisfaction due to uneducated auditors
Results Notification
  • Initial Result letter with initial determinations for each account

  • Final Result letter following the education session with the final results and error rate.

Haphazard receipt of denials and appeal deadlines prior to final results letter and education session.Haphazard receipt of denials and appeal deadlines prior to final results letter and education session.
  • Defeats the purpose of the TPE program

  • Requires additional FTEs to monitor TPE activity

  • Unclear indications for appeal

  • Takes away from the educational opportunity

Response OpportunitiesTime given to provider to review denied cases prior to education sessionNo consistency in timeline with records sent, denial notification, appeal requirements, and education sessionNo consistency in timeline with records sent, denial notification, appeal requirements, and education session
  • Requires additional FTEs to monitor TPE activity

  • Unclear indications for appeal

  • Does not enhance the program

  • Takes away from the educational opportunity

Education and Participants
  • Physician to physician

  • All denied cases reviewed and discussed

  • Ten days to submit additional documentation prior to final error rate being determined

  • Rare MAC physician participation

  • Cases denied on coding guidelines with no coder reviewing or on education call

  • Nurse auditor often misinterprets NCD

  • Auditor providing education often not the auditor whom reviewed the cases

  • Educator often disagrees with denial results but final error rate unable to be changed

  • Rare MAC physician participation

  • Cases denied on coding guidelines with no coder reviewing or on education call

  • Nurse auditor often misinterprets NCD

  • Auditor providing education often not the auditor whom reviewed the cases

  • Educator often disagrees with denial results but final error rate unable to be changed

  • Provider dissatisfaction

  • Increased administrative burden

  • Decreased credibility for the TPE program

Case ReviewAll denied cases reviewedMAC selects a portion of denied cases to reviewMAC selects a portion of denied cases to reviewPhysicians feel their opinion does not matter
Additional Documentation SubmissionHave 10 days after education session to submit documentationNone allowed after education sessionNone allowed after education sessionInability to demonstrate all that was available to support the case
Final Error RateDetermined after education session and additional documentation submission and review by QIODetermined prior to education session - no opportunity to change even if auditor errorDetermined prior to education session - no opportunity to change even if auditor error
  • Inaccurate representation of errors and provider compliance

  • · Provider dissatisfaction

  • Provider reputation to his/her peers, office staff, and administrative leaders misrepresented

Appeal Results
  • Do not influence future reviews

  • Denied cases are not appealed prior to education session to follow CMS guidelines for QIO process - once appealed, no further action can be taken by the auditing body

  • Unclear how appeal results will influence future reviews.

  • Appeal deadlines often occur prior to an education session.

  • Unclear how appeal results will influence future reviews.

  • Appeal deadlines often occur prior to an education session.

  • Fearful of unwarranted repercussions from MAC

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