Medicare Compliance & Reimbursement

Tip: Check with your MAC for a definite start date.

You can expect some extra scrutiny of your Medicare claims, a recent update suggests.

Details: On Aug. 12, the Centers for Medicare & Medicaid Services (CMS) announced the resumption of the Targeted Probe & Educate medical review program. “CMS is restarting the Targeted Probe and Educate (TPE) program to help educate providers and reduce future denials and appeals,” the agency said in its MLN Connects newsletter from that date.

Reminder: CMS began TPE on a more limited basis in late 2017, and its Probe & Educate program ran before that. Under the program, MAC medical reviewers conduct three rounds of review, selecting 20 to 40 claims per round, and target at-risk providers as opposed to looking at 100 percent of the claims. Then, Medicare providers receive a notification letter letting them know that their claims have been selected for an audit.

However, when COVID-19 hit, CMS said in a Frequently Asked Question (FAQ) set issued in March 2020 that “no additional documentation requests will be issued for the duration of the [Public Health Emergency] for the COVID-19 pandemic.” Then CMS quietly restarted regular prepayment medical review in August 2020 and post-payment review in June 2021.

As of press time, only Part B MAC WPS-GHA, DME MAC Noridian Healthcare Solutions, and HHH MAC Palmetto GBA had signaled a TPE review start date. “CMS has authorized WPS to resume the TPE program effective September 1, 2021. Providers selected for review based on data analysis aberrancies will receive notification prior to the start of their TPE review,” noted WPS in an Aug. 30 update. Other MACs are expected to follow suit and announce TPE start dates soon.

Tip: If you’re concerned about compiling additional documentation requests (ADRs) during the pandemic, extra help should be available from the MACs.

“CMS has directed the MACs to grant providers extensions to providing documentation when requested to help providers having administrative issues because of the Public Health Emergency,” said a CMS spokesperson. “Providers can get additional information about the program and how they could be impacted by contacting their respective MAC.”

Resources: See the brief announcement at www.cms.gov/files/document/2021-08-12-mlnc.pdf. More TPE information, including a link to a question-and-answer set with 2019 program stats, is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE. Read the WPS-GHA announcement at www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/resumption-targeted-probe-educate-tpe.