TPE Aims to Improve Medicare Claims

TPE Aims to Improve Medicare Claims

The Centers for Medicare and Medicaid Services (CMS) rolled out the Targeted Probe and Educate (TPE) programs for the Medicare Administrative Contractors (MAC) to begin identifying targeted providers and sending out round-one reviews by the end of last year. The TPE process is only used with providers that have high denial rates or unusual billing practices. According to CMS, the goal of the program is to help the provider to quickly improve through the focus probe and education effort.
Providers are targeted for TPE based on:

  • Analysis of billing data indicating “questionable billing practices”
  • High claim error rates from prior reviews or adjudications
  • Services that have high national error rates
  • Services that are a “financial risk to Medicare”

According to CMS, some of the most common claim errors are:

  • Missing signature of the certifying physician
  • Documentation does not establish medical necessity
  • Encounter notes lack support for all elements of eligibility
  • Missing or incomplete initial certifications or recertification for services

The basic steps in the TPE process are:

  • Targeted providers will receive a letter from the MAC requesting documentation for 20-40 claims
  • The MAC will review the documentation to determine if there are errors and recoupment should be made
  • Providers with denied claims will be invited to a one-on-one education session
  • Providers will have 45 days to make changes and improve (established by another production and review)
  • Providers that do achieve 100 percent compliance will not be reviewed for at least another year
  • Providers that do not achieve 100 percent compliance within three reviews in less than 1 year will be referred to CMS for additional follow up

Potential consequences of failing three reviews include:

  • 100 percent pre-payment review of all claims (charts must be produced and reviewed for approval of all claims submitted)
  • The MAC can extrapolate an error rate from a statistically valid sample (one of the reviews) over the universe of claims reviewed (potentially six years back), and make an overpayment demand for the percentage error of all the claims
  • Referral to a Recovery Audit Contractor (RAC) that has the same audit and extrapolation ability;
  • Referral to a Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC) for a fraud and abuse investigation
  • CMS can begin Medicare exclusion proceedings to terminate a providers’ participation
  • CMS can refer the provider to the Office of Inspector General (OIG) for potential criminal prosecution of billing fraud by the Depart of Justice (DOJ)

If you or your practice receive a TPE request, it is imperative that you understand the process and potential consequences. You may wish to obtain legal advice to protect all your appeal rights or consult with your practice management consultant.

Joettte Derricks

About Has 3 Posts

Joette Derricks, MPA, FACMPE, CPC, CHC, CSSGB, has 35 years of healthcare experience as an administrator, consultant, writer, and educator. Her extensive knowledge of third-party reimbursement, coding and compliance coupled with her operational “know-how” ensures that a client’s operation is productive, profitable and compliant.

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