CMS Announces Change in MAC Medical Review Process

As announced by the Centers for Medicare and Medicaid Services (PDF), CMS is expanding the existing Targeted Probe and Educate (TPE) pilot, which included hospitals and home health, to include all Medicare Administrative Contractors (MACs), effective October 1, 2017.  TPE will include targeted medical review and education along with an option for potential elevated action, up to and including referral to other Medicare contractors including the Zone Program Integrity Contractor (ZPIC)/ Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and others.  The goal of TPE is to reduce/prevent improper payments.  The purpose of this expansion is to reduce appeals, decrease provider burden, and improve the medical review and education process.

NHPCO will be working with each of the MACs to seek additional clarity and to publicize educational opportunities.  It is vitally important that each hospice pays very close attention to communication from the MAC on this issue and note the deadlines imposed.

CMS has developed a flow chart (PDF) that can be used for additional clarity about the process.

Members can access additional information on the NHPCO Regulatory page, and can direct any questions to regulatory@nhpco.org.

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