Comparison of KEPRO (QIO) and Targeted Probe and Educate (TPE) Processes | COSMOS Compliance Universe

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.


	KEPRO	TPE Process - Hospital Billing	TPE Process - Physician Billing	TPE Process Challenges/Burden
Initial Notification	One designated location	Hospital able to designate location	Providers Receipt of initial notification often unknown	Inability to identify notices and respond timely
Request for Records	Single 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 Records	Mail 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 Selection	Not applicable	Different 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
Criteria	Defined, 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 Knowledge	Trained 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 Opportunities	Time given to provider to review denied cases prior to education session	No consistency in timeline with records sent, denial notification, appeal requirements, and education session	No 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 Review	All denied cases reviewed	MAC selects a portion of denied cases to review	MAC selects a portion of denied cases to review	Physicians feel their opinion does not matter
Additional Documentation Submission	Have 10 days after education session to submit documentation	None allowed after education session	None allowed after education session	Inability to demonstrate all that was available to support the case
Final Error Rate	Determined after education session and additional documentation submission and review by QIO	Determined prior to education session - no opportunity to change even if auditor error	Determined 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