What to Expect From the Targeted Probe and Educate (TPE) Review Process

WPS Government Health Administrators (WPS GHA) is authorized by the Centers for Medicare and Medicaid Services (CMS) to conduct the Targeted Probe and Educate (TPE) review process. This process is required of the providers identified by Medical Review.

The TPE review process involves three rounds of pre-and post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. From there, CMS will determine if any additional action needs to be taken. Additional actions may include extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor.

What Can You Expect?

The following points were published on the WPS GHA website to outline the TPE review process.

WPS GHA will notify providers/suppliers in writing of their selection for the topic or CPT code under review, the data reasons for selection and the review process.
Provider/supplier reviews will consist of up to three rounds of prepayment or post-payment TPE claim review. WPS GHA will select the topics for review and the providers to be reviewed based on the current data analysis procedures outlined in CMS Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
WPS GHA may refer providers/suppliers to the Recovery Audit Contractor or the Unified Program Integrity Contractor if providers do not respond to Additional Development Requests and submit the requested documentation to WPS GHA.
If needed, education will be offered to the provider/supplier throughout the TPE process. Additionally, at the end of each round of claim review, WPS GHA will notify the provider/supplier in writing of the results and offer education on identified errors. Providers/suppliers with high error rates will receive on offer for one-on-one education on the specific errors that were identified. The goal for providers/suppliers is to learn from the education and improve the results in the next “round” to a low error category.
Providers/suppliers will move to the next round of claim review if the error rate remains at a high level. Providers/suppliers with a continued high denial rate after three rounds of Targeted Probe and Educate reviews will be referred to CMS for possible further action.
Once a provider/supplier has reached an acceptable error rate, the provider will be removed from further review. WPS GHA will continue to routinely monitor data on that service/provider.
Discontinuation of the review(s) may occur at any time if appropriate improvement is achieved during the review process.

If you receive a TPE letter, Yeo & Yeo Medical Billing & Consulting will be happy to help you with questions. Please contact us or make an appointment to speak with one of our experienced Medical Billers.

“Targeted Probe and Educate.” WPS Government Health Administrators, Centers for Medicare and Medicaid Services, 25 Sept. 2017.

Each month, the Office of Inspector General (OIG) publishes various Work Plans (topics) that target concerns raised by Congress, the Centers for Medicare and Medicaid Services (CMS) and other organizations, on which the OIG will focus for the current fiscal year or beyond.

Following are two recent targets posted for the fiscal year 2018.

Review of Medicare Payments for Bariatric Surgeries

Bariatric surgery is performed to treat comorbid conditions associated with morbid obesity. (A comorbid condition exists simultaneously with another medical condition.) Medicare Parts A and B cover certain bariatric procedures if the beneficiary has (1) a body mass index of 35 or higher, (2) at least one comorbidity related to obesity, and (3) been previously unsuccessful with medical treatment for obesity (CMS, Medicare National Coverage Determinations Manual, Pub. No. 100-03, chapter 1, part 2, § 100.1). Treatments for obesity alone are not covered.

The Comprehensive Error Rate Testing program’s special study of certain Healthcare Common Procedure Coding System codes for bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures (CMS, Medicare Quarterly Provider Compliance Newsletter, “Guidance to Address Billing Errors,” volume 4, issue 4, July 2014). The OIG will review supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with federal requirements [Social Security Act, §§ 1815(a) and 1833(e)].

Independent Physical Therapists’ High Use of Outpatient Physical Therapy Services

Previous OIG work found that claims for therapy services provided by independent physical therapists were not reasonable and were not properly documented, or the therapy services were not medically necessary. Medicare will not pay for items or services that are not “reasonable and necessary” [Social Security Ace § 1862(a)(1)(A)].

The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they complied with Medicare reimbursement regulations. The OIG’s focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Documentation requirements for therapy services can be found in Centers for Medicare and Medicaid Service’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 220.3

Learn more about the OIG Work Plans.

Please contact Yeo & Yeo Medical Billing & Consulting with questions regarding these topics.

In the world of credentialing, you can always expect changes in the process or variations between insurance carriers. To avoid interruptions in your practice’s reimbursement and revenue cycle, you’ll want to become familiar with the most recent changes. Staying up to date can be challenging, so we’ve compiled a few tips to keep your enrollments on the right track.

Provider Enrollment Changes

Important Documents
Banking information is necessary for Medicare. The provider must have a bank account opened in the practice’s name. Enrollment cannot be processed without a voided check or bank letter signed by an authorized bank official. The voided check must be from the practice’s bank account. It must also be an actual check; it cannot be a temporary check that the bank will issue until your checks come in.
It is also important to have malpractice insurance in place. You cannot practice without it, and many insurance companies will want a copy for enrollment. It’s also a requirement to keep your Council for Affordable Quality Healthcare (CAQH) profile updated. You’ll read more about the importance of CAQH below.
Processing Times
- Medicare: 30 days
- Medicaid: 30 days
- Commercial: 6-16 weeks
- Blue Cross Complete: 6 months
- Blue Cross Blue Shield of Michigan: 2 weeks
Blue Cross Blue Shield of Michigan (BCBS) Group Changes
As of January 1, 2018, group changes may be made only online. Paper applications will no longer be accepted. You must submit an Addendum G form to BCBS to gain access to a provider on the Provider Self-Service Tool located on WEBDENIS. New group enrollments and individual practitioner changes can still be made with paper applications.
Changes to TRICARE
As of January 1, 2018, TRICARE North combined with TRICARE South to become the new TRICARE East. Previously, TRICARE North was handled by Health Net Federal Services. Now, the Department of Defense awarded the contract to Humana Military. If a provider previously had a contract with TRICARE North, no action needs to be taken. The contract will be converted to Humana Military, and all dates of service before January 1, 2018, will still need to be billed to TRICARE North. All new provider enrollments must be done through Humana Military.

CAQH

Many insurance companies are now turning to CAQH for credential verification. One of the largest carriers is Blue Cross Blue Shield of Michigan. Blue Cross previously requested verification through PrimeHUB; an authorized individual would attest to the information on file for a given provider, or any number of providers. Now, Blue Cross sends requests for a provider’s CAQH profile to be updated and attested for. The attestation is crucial to provider enrollment – CAQH profiles must be attested for no earlier than 14 days before submitting enrollment applications. Blue Cross has advised us that they pull information from CAQH profiles every Monday.

PHOs

Provider Health Organizations are another helpful resource for provider enrollments. Providers can join one of these organizations and get help with credentialing. PHOs have a list of health insurance carriers they are partnered with and will handle all of the enrollments for those specific insurance carriers. This means that even if an insurance carrier has a closed network, being a member of a partnered PHO will allow enrollment to go forward. Joining a PHO will give you an advantage over providers who are not members of a PHO.

Providers should be warned that when they choose not to join a PHO, they risk being unable to get in a network with insurance carriers who have contracts with the PHO.

We hope these tips shed some light on changes in the credentialing process. Yeo & Yeo Medical Billing & Consulting is happy to offer additional information or assistance with your practice’s credentialing needs.

The Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act (MACRA), is a payment incentive program that rewards eligible clinicians based on standards of quality and value. Changes have been made to the QPP’s Merit-based Incentive Payment System (MIPS) for the 2018 reporting year. The changes affect all those who participate in the MIPS program. Those included in MIPS (about 45% of clinicians) are physicians, PAs, NPs, CNSs, CRNAs, as well as groups that include these clinicians. About 55% of clinicians are excluded from MIPS including clinicians and groups that fall under the low-volume threshold, providers billing Medicare for the first year, and groups with significant participation in Alternative Payment Models (AMPs).

The MIPS performance assessment is divided into four categories in which clinicians submit data. The assessment categories are Quality, Improvement Activities, Accountable Care Information, and Cost (new in 2018). Each category weighs differently into the overall performance score.

Summary of 2017 Requirements

Minimum reporting requirements were imposed in 2017, the first performance year for MIPS. A 90-day reporting period was implemented for the Quality and ACI categories. The Improvement Activities category had a 90-day reporting period as well, but it was not required. The Cost category did not have a mandated reporting period.

Last year’s performance category weights were as follows: Quality = 60%, Improvement Activities = 15%, and ACI = 25%.

Those who did not report any data in 2017 will receive a 4% penalty on their payment outcome for 2019. Those who reported only one Quality Measure or Improvement Activity or ACI will receive a 0% payment adjustment, while those who reported more will receive positive percentage adjustments to their payment outcomes in 2019.

Category Changes for 2018

Updates have been made to the reporting requirements for the 2018 reporting year. In its second year, the program will continue to minimize the burden on clinicians, coordinate care more efficiently, and ensure that the program’s processes and outcomes are meaningful. The transition to full implementation of the QPP is still in progress, so the requirements are still in a flexible stage working toward full implementation next year.

For the 2018 reporting year, there will be four categories for reporting as opposed to three categories last year. The four categories for this year are:

Quality is worth 50% of the total assessment score. Full-year reporting is required for this year. It requires clinicians to report six quality measures including one high-priority outcome measure. Alternatively, clinicians can select a specialty measure set. Each measure must be reported on 60% of the time, and each measure is worth three points. Those measures that don’t meet the completeness criteria will earn one point (except for small practices, which will earn three points).Clinicians may choose from more than 200 individual measures or 30 specialty measures. An all-cause readmissions measure is calculated from administrative claims for groups of 16 or more clinicians with at least 200 attributed cases in addition to the measures above. Bonus points are available for reporting additional outcomes or high priority measures as well as for using Certified Electronic Health Record Technology (CEHRT).

Improvement Activity is worth 15%. Clinicians must earn 40 points in this category to earn the full 15% of the score. Certified Patient Centered Medical Homes will receive 15 points. The requirements remain the same as in the 2017 reporting year. A 90-day reporting period is in place. Clinicians may choose from 112 improvement activities and must report up to four activities.

Advancing Care Information is worth 25% of the score. The reporting requirements remain the same as in the 2017 reporting year. This portion of the assessment is comprised of four required objectives: performing a Security Risk Assessment, E-Prescribing, providing patients access to their data, and Health Information Exchange. There is a 90-day reporting period. Clinicians may use the CEHRT from 2014 or 2015. They will receive a 10% bonus if they use only 2015. Exemptions from this category include:

–A significant hardship exception in which no five-year limit is applied. MIPS-eligible clinicians in small practices are exempt if there are 15 or fewer clinicians.

-An exemption is in place for hospital-based MIPS Eligible Clinicians and Ambulatory-Surgical-Center-based clinicians.

-An exemption also exists if the EHR has been decertified.

Cost is a new reporting category for the second year of the QPP. A full year of reporting is required and is worth 10% of the assessment score. The Centers for Medicare & Medicaid Services (CMS) will provide feedback based on 2017 claims data. All measures are calculated by CMS based on administrative claims collected for a full calendar year. No separate reporting is required. The measures for this category include total per capita costs for all attributed beneficiaries, Medicare spending per beneficiary, and episode-based measures. The clinician’s performance will be compared with that of other Eligible Clinicians during that performance period. The performance category score is then found by averaging the two measures.

Points earned in the four categories are combined to determine the comprehensive assessment score. Participating clinicians will receive either a 5% increase or decrease in their payment outcome in 2020 based on the 2018 assessment. Below is a table outlining the point value earned in the assessment and its corresponding adjustment to the payment received in 2020.

Points	Adjustment
≥ 70 points	Positive adjustment and an additional minimum adjustment of 0.5%
15.01 – 69.99	Positive adjustment
15.00	Neutral
3.76 – 14.99	Negative adjustment less than 5%, greater than 0%
0 – 3.75	Negative payment adjustment of 5%

Also New This Year

The performance threshold is being raised to 15 points in the 2018 reporting year.
Bonus points can be earned toward your final score for treating complex patients (five points), being a small practice (five points), and using 2015 technology when using the 2014 and/or 2015 CEHRT.
Virtual groups are included as a participation option for the 2018 reporting year. A virtual group is made up of two or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who have virtually come together to participate in MIPS for a performance period of a year.
A new policy is in place to address situations of extreme and uncontrollable circumstance such as hurricanes and other natural disasters. Those clinicians impacted by a natural disaster will automatically have the weighting of Quality, ACI, and Improvement Activities set to 0% of the final score.

Download this information as a business brief to share with colleagues.

An alternative to the MIPS assessment is the Advanced Alternative Payment Model (AAPM). Medicare administrators hope more clinicians will participate in APMs and are making revisions to make it easier to participate and more beneficial to the eligible clinicians. Please visit the Medicare website for more information about eligibility and the requirements of this alternative program.

Call on Yeo & Yeo Medical Billing & Consulting for Assistance

As QPP advances toward full implementation, the reporting requirements will continue to change. Yeo & Yeo Medical Billing & Consulting stays up to date on the changing requirements of the Quality Payment Program. Please call us with questions or concerns you may have about QPP reporting and assessments.

For additional resources, visit the following websites:

https://qpp.cms.gov

https://www.qppresourcecenter.com

The second-annual Cyren-Osterman Research U.S. security survey shows a significant disconnect between rising IT security spending and a low level of confidence in current protection, among many topics covered in the 24-page report.

Security Budgets Up Sharply

On average, survey respondents reported that IT security budgets grew a robust 17% during the past 12 months. That’s on top of a 21% increase reported one year ago in the first annual Cyren-Osterman Research survey. However, sixty-eght percent of businesses reported one or more breaches or infections during the prior 12 months, and significantly less than half believe they are well prepared to meet priority threats like ransomware, phishing and zero-day exploits.

The survey focuses on the current web and email security status and priorities of IT and security managers at organizations with 100 to 3,000 employees. The survey results allow security personnel to benchmark their own security posture and planning against their peers.

Security breaches are prevalent – Slightly more than two-thirds of the organizations surveyed – 68 percent – reported that they had experienced one or more breaches or infections during the past 12 months, with 29 percent reporting a successful phishing attack and 18 percent a ransomware infection that had gotten past their security defenses.
Ransomware is the #1 concern – Ransomware surged from fourth place in the 2016 Cyren-Osterman Research survey to the top of the heap of issues about which IT and security managers are concerned or extremely concerned (62 percent), slightly edging phishing (61 percent), and data breaches (54 percent).
Security concerns rule, controlling employees doesn’t – While threat categories are the top concerns among U.S. SMB security decision makers, only 24 percent expressed concern about shadow IT, with even fewer giving importance to controlling employee web behavior. (Our comment: this is a recipe for disaster)
Security effectiveness trumps cost – and everything else – Security effectiveness (85 percent) and speed of defense against new threats (74 percent) markedly outdistanced all other capabilities that were rated (reporting, user experience, management ease, etc.). Cost considerations were among the lowest-rated factors in evaluating a security solution.
Stopping threats in HTTPS is a priority – Fifty-nine percent rated as highly or extremely important the ability to perform SSL traffic inspection for threats, ranking it fourth among desired features in a web security solution. Fifty five percent indicated they have deployed an SSL inspection capability, which contrasts with a far lower deployment rate of 19 percent found in a similar survey in the UK in February 2017.
Few think highly of their current protection – Most SMB decision makers believe that the security deployed for their organizations is not doing well, with the largest “security gaps” around the threats of greatest concern. For example, while 61 percent rate phishing a top concern, only 39 percent rate their protection highly.
IT security investment is exploding at SMBs – Presumably driven by the poor opinion of current security, and the reality and risk of recurring infections and breaches, SMB IT security budgets jumped significantly for the second year in a row, rising 17 percent on average in the past year, following a 23 percent increase reported in the 2016 Cyren-Osterman Research survey.
SMBs have limited IT security staff – Respondents indicated that they generally have a low number of dedicated IT security staff members available to deal with security issues. We found that over half (52 percent) of the organizations surveyed have two or fewer security staff members, with the figure rising to 80 percent for the smallest cohort, with 100-500 employees.
Mobile device security is lagging behind – While 70 percent protect remote offices and roaming laptop use, only half protect company owned mobile devices, dropping to one-fifth providing protection of BYOD mobile devices, even if they connect to the corporate network.
Preference growing and nearly equal for cloud-based SaaS vs. on-premises – The preference in terms of deployment model for security solutions is now nearly equally divided, with 32 percent preferring on-premises solutions, and 29 percent preferring cloud-based SaaS – with the latter up sharply from 21 percent in the 2016 Cyren-Osterman Research survey.
Email security is now predominantly done in the cloud – Fifty-seven percent of SMBs rely on SaaS security for their email, considering together those who subscribe to a SaaS Secure Email Gateway (28 percent) and those who rely on the security provided by their SaaS or hosted email service provider (29 percent).
Cloud-based web security is moving up the adoption curve – Eighteen percent of SMBs reported that they subscribe to SaaS web security, with another 16 percent reporting deployment of “hybrid” cloud and on-premises solutions, and six percent relying on a hosted virtual appliance.
Security breaches cost significant staff time (and money) – After a security breach, organizations reported an average of 152 person-hours in IT staff time devoted to addressing the problem.

Download the full report here: https://blog.cyren.com/articles/survey-finds-security-investment-increasing-but-not-security

Two associates within Yeo & Yeo Medical Billing & Consulting have received professional credentials.

Traci Cook completed the required training to become a Certified Professional Medical Auditor (CPMA^®) through the American Academy of Professional Coders. The knowledge required for this certification includes medical documentation, fraud, abuse, and penalties for documentation and coding violations based on governmental guidelines. Traci’s expertise will benefit the company’s healthcare clients as she performs medical record audits to decrease risk and improve compliance.

Traci is a billing and coding consultant and an account manager and has been with Yeo & Yeo Medical Billing & Consulting since 1999. She is a Certified Professional Coder with expertise in the coding of diagnoses, services, and procedures for physician practices, clinics and third-party payors. She is a member of the American Academy of Professional Coders and the Michigan Medical Billers Association.

Denise Garrett completed the required training to become a Certified Physician Practice Manager (CPPM®), through the American Academy of Professional Coders. The knowledge required for this certification includes revenue cycle management, human resources, health information and general business processes. Denise’s expertise will benefit the company’s medical practice clients as she focuses on their business needs including operational efficiencies, staff training, and technology.

Denise is an account manager and has been with Yeo & Yeo Medical Billing & Consulting since 1998. She is a Certified Professional Coder and a Certified Foot & Ankle Surgical Coder, with expertise in the coding of diagnoses, services, and procedures for physician practices.

Learn more about medical billing and practice management consulting services offered by Yeo & Yeo Medical Billing & Consulting.

Since 1955, the State of Michigan has exempted various prosthetic devices from sales and use tax. In 1985, the Treasury issued Letter Ruling 1985-20 addressing sales of a specific type of dental prosthetic (dental ceramics), essentially including these dental prosthetics with other exempt devices. When Letter Ruling 1985-20 was issued, the sales and use tax acts exempted “any … apparatus, device, or equipment used to replace or substitute for a part of the human body …”

With the passage 100c of 2004 Michigan Public Acts 172 and 173, the sales and use tax acts directed that dental prosthetics were excluded from the statutory exemption under the definition of “prosthetic device.” These acts defined a “prosthetic device” as “a replacement, corrective, or supportive device, other than contact lenses and dental prosthesis, dispensed under a prescription, including repair or replacement parts for that device, worn on or in the body …” Since Letter Ruling 1985-20 was still in effect, the 2004 Michigan Public Acts did not change how prosthetic devices were taxed.

In June 2017, the Michigan Department of Treasury announced that it had revoked Letter Ruling 1985-20 effective July 1, 2017. For transactions before this date, dental labs do not need to collect sales tax on custom dental products.However, the Treasury now considers the dentist the end user, as they use the material in the services they provide to their patients.After July 1, dental lab sales of dental prostheses to dentists are subject to sales tax based on the sales price of the prosthetic.

Because these transactions will now be treated as a sale at retail, dental labs may claim the industrial processing exemption for property used in manufacturing its products, if the property used to make such dental products qualifies for the industrial processing exemption.

Please contact your Yeo & Yeo professional if you have questions.

Affiliated Medical Billing has changed its name to Yeo & Yeo Medical Billing & Consulting, announced Thomas E. Hollerback, President & CEO of Yeo & Yeo CPAs & Business Consultants and its affiliates.

The name change leverages the strength and longstanding reputation of the Yeo & Yeo name, reflects the broader range of professional services the company offers and aligns the affiliate under a single Yeo & Yeo brand name. The name change will create a unified name for all three of the firm’s affiliates: Yeo & Yeo Medical Billing & Consulting, Yeo & Yeo Technology, and Yeo & Yeo Financial Services. The new doing business as name is effective immediately and will be implemented throughout the calendar year 2017.

Announced in conjunction with the name change, Julia M. Lowe, CPC, former president of Affiliated Medical Billing, retired from the company after 19 years of providing medical billing and consulting services for physicians and healthcare organizations, and more than 40 years dedicated to serving the healthcare profession. Under Lowe’s leadership, Yeo & Yeo’s medical billing affiliate started as a two-person team and grew to a highly successful organization with 18 professionals.

Kati Krueger was named president of Yeo & Yeo Medical Billing & Consulting effective May 1, 2017. She has an extensive background with the medical billing affiliate, having joined the company in 2002. Krueger held the position of billing manager and also served as marketing manager for nearly five years, overseeing client relations and business development opportunities. She has more than ten years’ experience in medical billing and revenue cycle management, helping physicians and group practices throughout Michigan to be efficient and compliant. She has served as vice president since August 2016. Krueger is a member of the Medical Group Management Association, and holds a bachelor’s degree from Saginaw Valley State University.

“During the past year, Yeo & Yeo CPAs implemented Lean Six Sigma methodologies that focus on greater efficiency and quality in our audit and tax practices – it is a process we refer to as YeoLEAN. Now, under Kati’s leadership, Yeo & Yeo Medical Billing & Consulting is employing the YeoLEAN concepts that have allowed our medical billing professionals to streamline processes and focus on greater value for our clients,” says Kimberlee Dahl, Director of Marketing for Yeo & Yeo.

“I am excited to lead the future advances at Yeo & Yeo Medical Billing & Consulting under its new name. Our YeoLEAN process improvements will be ongoing, and the process has already led to the implementation of new software capabilities and paperless technologies, more efficient insurance reimbursement processing, and timelier communication with our healthcare clients – all with the goal of helping them maximize their profitability,” adds Krueger.

Yeo & Yeo Medical Billing & Consulting will continue its mission to be a leading provider of medical billing and practice management consulting services for the healthcare industry, as it has since 1998.

Our affiliate, Yeo &Yeo CPAs & Business Consultants, recently posted an excellent article about what to know when facing a HIPAA audit. We thought this article would be great to share with you as well. To read this post, click here.