This transcript was auto-generated using Adobe Premiere Pro.
00;00;05;01 - 00;00;21;04
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond, where we connect you to what matters in the ever changing world of hospice and palliative care. The Gift That Keeps On Giving: TPE Insights and Strategies. Brian.
00;00;21;16 - 00;00;22;01
Bryan Nowicki
Hey Meg.
00;00;22;22 - 00;00;40;25
Meg Pekarske
We're still talking about TPE. I think in preparing for this. It's like how many podcasts over the years have we recorded on TPE? And just as a tickler. Our hundredth episode is coming up here at HB in October, so.
00;00;41;23 - 00;00;43;02
Bryan Nowicki
It's quite a milestone.
00;00;43;15 - 00;00;45;17
Meg Pekarske
Stay tuned for fun. Yeah.
00;00;46;02 - 00;00;50;24
Bryan Nowicki
Yeah. Hopefully not more TPE podcasts before that, but marketing.
00;00;50;26 - 00;01;40;09
Meg Pekarske
Is working out something for our listeners. But but now on to serious business of TPE in I think why we wanted to do this episode. Not that TPE is new or whatever, but I think really to provide some thoughts on potential strategies and talk about some tools that we have available for folks and what we think is negotiable and not negotiable in terms of responding to this. So, so quick refresher brian and I think every mac is doing TPE right now. But but what are the thresholds and how are they working and and sort of the nuts and bolts here.
00;01;40;21 - 00;02;26;17
Bryan Nowicki
Right? So, so TPEs come in lots of different flavors from all those Max Angus and Paul Meadow they could relate to routine home care. GP focus on long length of stay and other items they've evolved through the years. We've done been doing these for years, so these are not things that are going away. They are evolving over time. And the typical TPE, it starts with round one where you're going to get a letter that says, Hey, you're on TPE and then after that you're going to get electronic notices or requests for records between 20 to 40 claims of documents they're going to be asking for. And i think more recently it's trending closer to the 40 number of claims.
00;02;26;17 - 00;03;34;28
Meg Pekarske
Yeah, I haven't seen anyone get less than 40 in the last, I don't know, six months or a year. Just seems like really automatic. I think what they are still sticking to except for a new provider GP, which is whole nother thing is they are not pulling typically all 40 and a month like they are spacing it over several months. But I think the 40 claims to do is still a lot in terms of cashflow delay. I mean even if you get all of your claims paid right, you have whatever it is, 41 days to respond or 45 days to respond and then they have 30 days to respond. I mean, suddenly your cash flow is starting to look fairly different. If you have 40 claims now, if you're a giant program, that's going to have a different effect. But we're seeing clients with the census of one 5200 still get 40. They're not necessarily doing something less because your census is smaller, which to me seems somewhat unfair. But same way, I guess.
00;03;34;28 - 00;03;58;03
Bryan Nowicki
Brian Yeah, well, yeah, I mean it's another drain on resources and disproportionate, but you know, with, with the pressure that CMS is getting from Congress, a lot of the pressure from enforcers, this is another way where they're kind of taking it to the hilt and using tpz for all their worth. In addition to expanding other kinds of audits that I'm sure we'll talk about another podcasts.
00;03;58;09 - 00;05;34;02
Meg Pekarske
So yeah, so these thresholds, which are another thing they keep scratching my head is, you know, if you're with Palmetto, you might be at a 15% threshold or 20% threshold to get off of TPE, but CGM is your 25. So there's still, I think, you know, why is one like a ten percentage difference is pretty significant in terms of payment error rate. But I will say I think because something that we have touched down in other podcasts and continues to partially be a trend is the number of clients that are going to round two and round three TPE and that I think clients have been able to truncate or get off of TPE if they've made significant improvement, even if you're not exactly at that payment error threshold that they publish, which I think is good that banks are looking at it. And because when you look at the guidance and the reworking of TPE from a number of years ago, they're really trying to focus on improvement. And like I think having an arbitrary number shouldn't necessarily be what you're focused on, like, oh, you're at 23% instead of 20%, but you brought it down from 60 or 70%, right? I mean, keeping people on, especially when they're pulling 40 every time, is is a lot.
00;05;34;02 - 00;06;27;09
Bryan Nowicki
So yeah, pull all the levers. You can mean there's opportunities to advocate with the Mac about being closed about what claims they're pulling. I mean, is it fair for them to keep pulling claims that are going to turn up the same errors, even though you've corrected an issue? I mean, there's something about the timing of the claims that they pull where they're supposed to allow education to take hold and allow you to correct problems. But if it's like an election related problem, you might not have an opportunity to correct that. So there may be opportunities. And Meg, I agree, it's these numbers are arbitrary. The 15, 20 or 25% error rate you've got to beat to get off of TPE. And the interactions with your MAC may be arbitrary as well, but but that doesn't mean don't try the arbitrary ness may come in your favor in some of these circumstances. So keep advocating.
00;06;27;18 - 00;08;28;04
Meg Pekarske
Yeah, I would say we have successfully gotten people off, even if they're not right at the threshold or even if they're not willing to like not go to around to they cut round to short. If you're doing well. So sometimes it can be helpful to use counsel in a very strategic way to sometimes do that reach out. I mean, you can ask for it yourself too. But again, TPE is something I think you got to be able to build your infrastructure to try to handle the best you can internally as opposed to use outside counsel. But with that said, the heart of this is we do have some tools, have clients want to email us that are for TPE. So it's sort of a do it yourself kind of thing. And I think throughout my entire career and I learned this from my mentor, Mary Michael, you always want to have like things that you make available to people for free. Hence this podcast or we I've written a zillion toolkits in my lifetime, which I will never write another one. So that is, you know, not going to happen. But we wanted to make available to people some type tools if they are on TPE that they can sort of do it there themselves. So folks listening who are interested in that, they can just email us and we can send those to that. But the first are some I always think the gold standard, if you can do it, is to write a brief patience summary, one page that gets the highlight as to why this person is eligible for, you know, hospice. If it's a routine home care kind of year, long length of stay or level of care if it's GAAP or continuous care. But Bryan, you and I worked on these. What's the essence of this? How do you do anything that's worth doing in a page?
00;08;28;29 - 00;09;38;17
Bryan Nowicki
Well, yeah, and I think it it depends upon getting right to the point. And for something like routine home care, if that's what they're reviewing because of length of stay the fastest way to start speaking the language of the auditor is talk the LCD. You lay out some standards and then you immediately start applying the LCD and hopefully you can make an argument that the patient meets the LCD. That's the the most persuasive way. If you have that argument, that'd be the one you'd want to put in this one page, one and a half page document that you're submitting with the medical records for Gypsy. When they're focusing on that, it's getting right to the criteria for GAAP pain control symptom management at the end of a covered hospital stay require the patient requires medication adjustment, observation. Those are all taken right from the regulations or the manuals. So line up your facts against those and you could do the same thing for continuous home care if that becomes a subject. But get right to the standards, line up your facts, site two pages and you know, make it a real succinct submission.
00;09;39;02 - 00;12;58;06
Meg Pekarske
So I do think folks listening are like, I don't have time to do that. And I think if you're doing fine on TPE and you're trending in the right direction, then maybe making that investment is not helpful and you double down on just making sure your records are responsive and ordered in an easy to use way and all that stuff. So I know in talking to a lot of clients over the last year about a lot of folks are not doing patient summaries. However, folks who are in a second or third round, they hadn't done patient summaries. I think that they're now, you know, trying to to put in that extra time, too, because I do think it can can make a difference because it is sort of a dot connecting kind of exercise so people can take it or leave that. But I think the thing they can't take or leave is you got to get organized. And I just am finishing up the slides for a presentation I'm doing at NHP CEO with Amanda Tippin at Trust Bridge, and it's about sort of audit strategy and infrastructure. And one thing that we're really emphasizing in that presentation, I think the same goes for PPE is get got to have a tracker from the very get go and, and what do I mean by tracker? It's an Excel spreadsheet that keeps track of all the patients being requested and how that follows through the appeal process. So you're not meeting deadlines, missing deadlines, or, you know, you don't understand how things are are related to one another. So I think that's a non-negotiable. We've had clients who have missed some deadlines because they they weren't organized. And so I think you got to front load that and have Prager around Per TPE. And if you want to keep it on all one spreadsheet. Yeah, do that. But you got to you want to have different tabs for different TPE because I think one thing you and I deal with on sort of the programing integrity type audits, which TPE is not bad, is that have you what is your education from Max band before and how have you how have you fared in terms of because right claim denials are considered education. So if you get everything overturned and let's say you have a you pick audit three years from now, you'd want to be able to have that evidence like, hey, my claims have gotten reviewed before and I was told I was doing everything right. And so having, you know, something that you can can track the final adjudication of a matter all the way to ALJ or whatever I think is incredibly important. I'm passionate about that. Right. That's not coming across. I'm passionate about being organized on that because you can't do anything if you're not organized. Right. And you cannot be strategic if you're not organized and you don't have good tracking tools. Right. So.
00;12;58;19 - 00;13;54;09
Bryan Nowicki
Well, that's that's exactly it. And we do these tracking tools when we're when we're asked to help with clients, and they're invaluable. I have a number of hearings every month about relating to TPS number, ALJ hearings, and you go to a tracking tool and you can see, well, what we're all the decisions before we got to ALJ and what's the patient name dates of service under you the kind of it and it's all at your fingertips you build these from the beginning and it doesn't become that onerous of a task. So it's a big spreadsheet, but you're filling in these columns in rows over weeks and months, and then when the time comes and you need it for that project, it's all there. And like you were saying, you get audited by an unrelated by every program integrity auditor. You can use this information to your benefit there as well. So yeah, I agree. Non-negotiable. Use that tracker. It's very important.
00;13;54;12 - 00;14;44;12
Meg Pekarske
Yeah. And so you know and then you're you can also track on a real time basis what's your payment error rate. Right. That's a driver in all of these thresholds is what's your payment error rate. I mean they track claim error rate, but you can have a claim error rate of 100% and a payment error rate of 2%. Right. Like people who got hit on physician visit denials or whatever. Right. That's a very small amount of an overall gap claim, but they got a lot of denials. So they had a really high claim error rate, but their payment error rate, the percentage of that quote, error is very small. And so our tracker has like a formula that sort of adds that up.
00;14;44;22 - 00;15;03;22
Bryan Nowicki
Yeah, I went through that recently and it was kind of a real life example, a 60% claim error rate and 11% payment error rate. So yeah, those numbers are important. Dig into those numbers because the percentages may surprise you about how well you're doing despite the number of claims that could be denied.
00;15;04;19 - 00;16;49;23
Meg Pekarske
Yeah. So I guess take it from us, someone who we are managing hundreds and hundreds of audits that the only way we can do that is we're really organized and I have a lot of infrastructure. And obviously, you know, most folks aren't going to be managing hundreds of audits. But I think the how we do that in an efficient way is you have that infrastructure. And I think for for folks coming to an HPC CEO, you know, hopefully you can attend my session where we're going to talk about that sort of in more of the context of program integrity audits. But, you know, it all is somewhat the same is you gotta put in the time, even if you're like, I don't have time to deal with this. I just got to respond to this. You have to prioritize building the infrastructure or else you're always chasing your tail and you're not building anything, right? You're just reinventing the wheel each and every time you do an audit. And that's, that's or TPE. And so I think that's really, really inefficient. And for those CEOs who are listening, I think it's something you really need to to push your compliance folks to do and ask them that you know, these questions of what infrastructure they have, because that's how you're going to be able to, you know, have high quality in terms of I'm always doing things the same. And, you know, you're going to be able to to see at a glance where things are at and how you're fairing. So so I will get off my soapbox now. Brian And yeah.
00;16;50;12 - 00;16;52;11
Bryan Nowicki
I think we all got the message. We all get the.
00;16;52;11 - 00;17;11;08
Meg Pekarske
Message broadcast, but I'm just still surprised on how many clients I talk to who really still sort of don't have a uniform method of doing that. And I think that that that's really a mistake. I don't say mistake very often, Brian.
00;17;11;10 - 00;17;18;12
Bryan Nowicki
You know, it's often, you know, you could improve this or that. But yeah, this is one of the bright lines that that's out there.
00;17;18;26 - 00;17;47;26
Meg Pekarske
Yeah. So awesome. The world is all about data analytics and if you don't track your own data with us, you're not going to be able to do any of your own analytics and your appeal so well. Great conversation, Brian, and folks who want those tools, please reach out to us and we can email them over to you. Thanks for your time. Brian and I bet I'm going to put chips on it that we're going to talk about TPE again in the future.
00;17;48;05 - 00;17;56;06
Bryan Nowicki
Yeah, thanks a lot. Mag. Probably so, but it's always new information, always good talking with you.
00;17;56;06 - 00;18;13;29
Meg Pekarske
Well, that's it for today's episode of Hospice Insights, The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at HuschBlackwell.com or sign up wherever you get your podcasts. Till next time, may the wind be at your back.