Medicare Initiates Targeted Probe and Educate Reviews

Medicare Initiates Targeted Probe and Educate Reviews

Audit results are an opportunity for providers to learn and improve billing accuracy.

Last year, the Centers for Medicare & Medicaid Services (CMS) replaced its method of selecting targets for complex medical reviews with a new strategy called Targeted Probe and Educate (TPE). Medicare Administrative Contractors (MACs) will focus on providers who have the highest claim denial rate, or whose billing data differs significantly from their peers.
Having MACs (rather than CMS) select the topics for review and provide the 1:1 education has shown positive results in the TPE pilot programs. Fewer appeals and increased provider education resulted in decreased denial rates for most providers.
Many MACs have posted on their websites this year’s TPE topic of review, including documentation needed, helpful hints, and round dates.
For example, First Coast Service Options (FCSO) — the MAC for Florida, Puerto Rico, and the U.S. Virgin Island — began TPE on Oct. 1, 2017. FCSO began conducting TPE on post payment Part B claims, only. According to FCSO, prepayment TPE was proposed to start March 2018 for Part B; however, at the time of this writing, the first prepayment TPE topic of review for Part B is under consideration, to be determined based on data analysis.

What TPE Means for You

If you are selected to participate in the TPE process, you’ll receive a notification letter. The notification letter provides the details of the new process, including the specific services under review and an additional documentation request (ADR).
The TPE process may include up to three rounds of probe and educate, with each round allowing the provider time to correct identified issues before the next round begins. Each round involves the review of 20 to 40 claims per provider, per service.
At the end of each review round, the MAC sends the provider a letter detailing the results of that round of claims review, including an explanation of claim error(s). This letter may be sent before or after the 1:1 education. A claim that is denied because of the review is subject to appeal. If a claim denial is appealed and overturned, this is taken into consideration in subsequent rounds.
The education provided in each round is developed based on the review findings from the most recent review completed. The education should improve specific issues found in the review. The goal is for providers to learn from the education and to improve their billing accuracy. At the end of each round and following education, providers are given six to eight weeks for documentation and process changes. This allows the provider an opportunity to demonstrate sufficient improvement through claim review during subsequent rounds of probe review.
When a provider has reached an acceptable error rate, the TPE process will end and the MAC will notify the provider of successful completion. Error rates will vary by individual statistical data, geographical areas, claims data, etc. If sufficient improvement is achieved through claims review, TPE may be discontinued after any round. If improvements are not made, the MAC will
refer the provider to CMS for additional actions, which may include 100 percent prepay review, extrapolation, referral to a recovery auditor, etc.

Don’t Be a Target

Prevention is the key to avoiding TPE. Having a strong compliance program, including regular chart reviews and internal education, will reduce denials and lessen the chance that your practice will become a target of complex medical reviews.

Helpful Compliance Links

If you’d like to build a strong healthcare compliance program, go to Healthicity’s Resource Center at
Demonstrate you know how to effectively develop, implement, and monitor a healthcare compliance program by obtaining the Certified Professional Compliance Officer (CPCO™) credential.

Christine Hall, CPC, CPB, CPMA, CRC, CPC-I, is an associate consultant with Acevedo Consulting, Inc., a healthcare compliance firm, and has almost 30 years of healthcare management experience. She is a member of the Stuart, Fla., local chapter.
Follow-up Question and Answers — Target, probe and educate: Reducing provider burden (A/B) (Dec. 14, 2017):

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