By: Matt Fischer
In 2014, the Centers for Medicare and Medicaid Services (CMS) started a program that combined the process of reviewing a sample of claims with providing follow up education as a way to help reduce errors in the claim submission process. This is called the Targeted Probe and Educate Program (TPE). The goal of the program is to help providers and suppliers identify errors made and quickly make improvements. CMS has acknowledged that since its inception the program needs improvements and that this type of review can be burdensome. Most providers and suppliers never experience a TPE review; however, for the ones that receive notification, here are the top five things you should know before moving forward:
- Who is selected?
Medicare Administrative Contractors (MACs) use data analysis to identify providers and suppliers with high error rates or unusual billing practices (i.e. they vary significantly from their peers). The focus is placed on particular items or services with a high national error rate and that are a financial risk to the Medicare program.
- What is the process?
If selected, you will first receive a notification letter. This letter will provide the services under review in addition to a local MAC contact person. The letter will also identify a sample of 20 to 40 claims to be reviewed. Once the review is complete, a summary results letter will follow outlining the error rate and next steps. This is considered one round. Overall, the TPE process is up to three rounds. With each round, the provider and supplier will be provided time to correct any identified issues.
- What are the common errors?
Errors can include simple mistakes such as missing signatures or certification documents to more complex denials such as lacking medical necessity or notes failing to support all elements of eligibility.
- Can I be subject to multiple reviews at one time?
Yes, providers and suppliers could be subject to separate probes for more than one item or service.
- What do they mean by education?
The education will be tailored to the most recent round of review and based on the errors identified. The education will address the errors along with the specific corrections that need to be made.
Here are some other important reminders…the Medicare Targeted Probe and Educate program does not replace other automated MAC reviews such as utilization reviews; you are still required to respond to and are subject to other records requests from other contractors and agencies (e.g. CERT, QIO, UPIC, OIG); and there are no changes to the appeals process. If notification is received, it’s important to know what to expect during this process.