In The News

Targeted Probe and Educate (TPE) Process (from CGS)

The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) process, effective September 1, 2021. Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. You may reference the Medical Review Activity Log for a list of review topics. Previous postpayment service-specific reviews will be phased out.

Key Points

  • CGS selects providers for the TPE process based on the following:
    • Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or
    • On targeted review and transitioned to the TPE process based on error rate results; or
    • On service specific review error rate results.
  • CGS will mail a notification to those who have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information.
  • TPE consists of up to three rounds of review with up to 20-40 claims selected (prepayment or postpayment) with each round. Subsequent rounds will begin 45-56 days after individual provider education is completed. The review may be discontinued if appropriate improvement and an error rate below the target threshold is achieved during the review process.
  • An Additional Documentation Request (ADR) is generated for each claim selected. CGS has 30 days (prepayment) or 60 days (postpayment) from the date documentation is received to review and make a payment decision.

    NOTE: No response to ADRs counts as an error when calculating the error rate. CGS recommends using myCGS, our secure online web portal to submit documentation in response to medical review ADRs.
  • For additional information, please reference the myCGS User Manual.
  • If you are not already registered to use myCGS, enrollment instructions can be found under the Introduction tab.
  • A review results letter will be mailed at the conclusion of each round. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
  • Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS also offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Questions and education requests may be sent to: [email protected].
  • The TPE review process includes up to three rounds of a prepayment probe review with education. If the denial rate remains high after three rounds, CGS will refer the provider to CMS for additional action, which may include: additional rounds of TPE review, 100% prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. The review may be discontinued if appropriate improvement and an error rate of < 25% is achieved during the review process.

Resources

 

USING YOUR BUDGET FOR CALCULATING LOST REVENUES FOR PRF REPORTING (From The Health Group) 

Three methods are available to healthcare providers for determining lost revenues eligible to be applied as a qualified use of Provider Relief Funds.  These are:

  • Option 1: Actual 2020 and 2021 revenues compared against 2019 revenues,
  • Option 2: Actual 2020 and 2021 revenues compared against 2020 budgeted revenues, or
  • Option 3: Alternate lost revenue computation.

We have received numerous inquiries regarding the use of budgeted revenues in the determination of lost revenues.  The following is provided by HRSA relating to the use of budgeted information:

“Lost revenues are calculated for each quarter during the period of availability, as a standalone calculation, with budgeted quarters serving as a baseline. For each calendar year of reporting, the applicable quarters where lost revenues are demonstrated are totaled to determine an annual lost revenues amount. The annual lost revenues for the years included in the period of availability are then added together. There is no offset.

Reporting Entities may use budgeted revenues if the budget(s) and associated documents covering the Period of Availability were established and approved prior to March 27, 2020.”

“When reporting use of Provider Relief Fund payments toward lost revenues attributable to coronavirus, Reporting Entities may use budgeted revenues if the budget(s) and associated documents covering calendar year 2020 were established and approved prior to March 27, 2020. To be considered an approved budget, the budget must have been ratified, certified, or adopted by the Reporting Entity’s financial executive, executive officer, or other responsible representative as of that date, and the Reporting Entity will be required to attest that the budget was established and approved prior to March 27, 2020. Documents related to the budget, including the approval, must be maintained in accordance with the Terms and Conditions.

https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-lost-revenues-guide.pdf specifically identifies the 2020 Budgeted Revenue as the basis for calculating budgeted revenues versus actual revenues for 2020 or 2021.

Many consultants are informing providers that they need a budget for 2021 for comparison to the actual revenues for the first two (2) quarters of 2021.  Other consultants are recommending the use of budgeted revenues for 2020 to actual revenues for 2020; however, they recommend using actual revenues for the first two (2) quarters of 2020 to be compared against actual revenues for the first two (2) quarters of 2021.

It is no wonder why many providers are confused.  HRSA has presented the following information which clearly indicates that a qualifying 2020 budget is not only used for comparison to actual 2020 revenues, but also that the first two (2) quarters of the 2020 budget are used for comparison against actual revenues for the first two (2) quarters of 2021.  As evidenced by the HRSA presentation, the first two (2) quarters of the 2020 budget are repeated for comparison against the 2021 actual revenues to determine lost revenues.

All providers are responsible for their submission and, accordingly, must select the process for identifying lost revenues; however, we believe the following as presented by HRSA is clear regarding the use of a qualifying 2020 budget (approved before March 27, 2020) solely as the basis against which actual revenues will be compared for both 2020 and the first two (2) quarters of 2021.  This approach makes sense as the 2020 budget would have been developed and accepted (before March 27, 2020) without considering any COVID-19 PHE impact, thus providing an appropriate comparison to actual revenues generated.

The entire HRSA presentation regarding “Period of Availability and Lost Revenues" is available here.  The information presented in the above slide has not been altered by any of the subsequent information released by HRSA.

 

 

COVID Vaccine For Kids Ages 5 To 11 Is Safe And Effective, Pfizer Says

Matt Rourke/AP

The first results from the highly anticipated trial studying the effectiveness and safety of the Pfizer and BioNTech COVID-19 vaccine for children ages 5 to 11 showed promising results.

The pharmaceutical companies said early results of their trial indicate the vaccine is safe for children and establishes a strong antibody response against the virus.

Giving a two-dose regimen of 10 μg (micrograms) administered 21 days apart for children between 5 and 11 years old was well tolerated, according to Pfizer and BioNTech. Side effects were also generally comparable to those of people between the ages of 16 and 25 years old who received the vaccine.

This trial used a smaller vaccine dosage, 10 micrograms, rather than the 30 microgram dose used for people 12 and older. The dosage was selected as the preferred dose for safety and effectiveness in young children.

News of the results come as pediatric cases of COVID-19 are increasing amid a nationwide surge of infections.

"Since July, pediatric cases of COVID-19 have risen by about 240 percent in the U.S. — underscoring the public health need for vaccination. These trial results provide a strong foundation for seeking authorization of our vaccine for children 5 to 11 years old, and we plan to submit them to the FDA and other regulators with urgency," said Albert Bourla, the chairman and CEO for Pfizer.

"Over the past nine months, hundreds of millions of people ages 12 and older from around the world have received our COVID-19 vaccine. We are eager to extend the protection afforded by the vaccine to this younger population, subject to regulatory authorization, especially as we track the spread of the Delta variant and the substantial threat it poses to children," Bourla said in a statement.

Despite the strong results, it will be some time before the general public can see an official rollout of vaccines for children ages 5 to 11. Once analysis of the trial is completed, Pfizer and BioNTech will submit the results "in the near term" to the Food and Drug Administration for review and possible emergency use authorization.

A Vaccine For Children Is Not Likely To Be Approved Until The End Of Year

And even if the FDA grants that authorization, Dr. Francis Collins, director of the National Institutes of Health, recently told NPR that parents and caregivers will likely have to wait until the end of 2021 before a COVID-19 vaccine is fully approved for young children ages 5 to 11.

Trial results for children under 5 years of age could come later this year, the pharmaceutical companies said.

"Already in March 2021, we have started the study to evaluate the immunization of younger children. Our objective was to generate and submit the data for schoolkids to regulatory authorities around the world before the winter season begins," BioNTech CEO and co-founder Ugur Sahin said.

 
 

An FDA Panel Says Only High-Risk Americans And Those 65+ Should Get COVID Boosters

Hannah Beier/Bloomberg

In a surprising vote, a panel of advisers to the Food and Drug Administration on Friday recommended against approval of a booster dose of the Pfizer-BioNTech COVID-19 vaccine for people 16 years and older.

The 16-2 vote against broad use of the booster, which would be given about six months after completion of the two-dose immunization regimen, dealt a setback to Pfizer and complicates the FDA's approach to boosters.

After a brief intermission following the rejection, FDA officials returned to the meeting with a revised booster question. The panel then voted 18-0 in support of the agency authorizing a booster shot of the vaccine for people 65 and older or at high risk of severe COVID-19.

The FDA then polled the panel members for advice on other groups of people who might be considered for a booster. Though not an official vote, the panel members unanimously supported authorization of a Pfizer booster dose for health care workers or others at high risk of occupational coronavirus exposure.

The agency typically follows the advice of its advisory committees, though it isn't required to. The Biden administration said in August that it planned to make booster shots available during the week of Sept. 20. That announcement was controversial because it came before the FDA had weighed Pfizer's application and before the Centers for Disease Control and Prevention's own panel of experts on immunization practices could consider the need for boosters.

The rise of the highly infectious delta variant of the SARS-CoV-2 coronavirus and some evidence that the Pfizer vaccine's protection against infections wanes with time are two of the factors that were cited in support of a booster.

But presentations Friday generally showed that the vaccine is still effective in protecting immunized people against severe illness, hospitalization and death in the United States.

Separately, however, an analysis published Friday in the CDC's "Morbidity and Mortality Weekly Report" found that the Pfizer vaccine's protection against COVID-19 hospitalization dropped from 91% during the first 120 days after vaccination to 77% in the days after that.

Over the course of the meeting, speakers from the FDA, Pfizer, the CDC, Israel and the U.K. presented data on the state of the coronavirus pandemic, experience with the Pfizer vaccine and lab tests.

The most direct support for the Pfizer booster came from laboratory work and a clinical study done by Pfizer that involved a little over 300 people.

"The difficulty for the committee is that you're making incredibly important policy decisions very rapidly in a situation of uncertainty," said Jonathan Sterne, a statistician from the University of Bristol who made a presentation to the panel.

 

Meet Our Keynote Speaker for the 2021 HHAC Conference!


Meg Johnson

Meg Johnson has motivated people of all abilities with her motto: When life gets too hard to stand, just keep on rollin’! Meg fell off a cliff and broke her neck in 2004, at the age of 22. She spent four months in the hospital recovering from multiple injuries and returned home without the use of her legs, back, stomach, or hands – a quadriplegic. Wheelchair bound and determined, Meg refuses to sit still. Since she was paralyzed, Meg has competed at the national Ms. Wheelchair America pageant in New York, winning the Spirit Award; founded and directs Ms. Wheelchair Utah; instituted a service outreach program; and authored several books. She received the Athena Award, which recognizes inspiring women in business. Meg’s influence is felt around the world as she reaches people through her YouTube channel, newsletter, and presentations. Her story is highlighted in many news outlets including newspapers, magazines, television, and documentaries. Meg has been married to her husband, Whit Johnson, since 2008 and they have two daughters and many tea parties.

 

 
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