Part B Insider (Multispecialty) Coding Alert

Targeted Probe And Educate:

Check Out the Latest Updates on TPE Medical Reviews

Published on Fri Sep 17, 2021

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Tip: Check your individual jurisdiction’s topics ASAP.

Whether you are ready for Targeted Probe and Educate (TPE) medical reviews to restart or not, they are happening.

Details: The Centers for Medicare & Medicaid Services (CMS) paused the TPE program when COVID-19 hit in March 2020, saying it would stay paused for the duration of the COVID public health emergency (PHE). But on Aug. 12, CMS announced it would resume TPE. The agency did not provide any specifics in its MLN Connects newsletter announcement, including a start date.

However, Part B Medicare Administrative Contractors (MACs) have started updating their websites with TPE review confirmations as well as active review topics. Read on for the details.

WPS: “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,” Part B MAC WPS-GHA noted in an Aug. 30 alert. Check out WPS guidance at www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/resumption-targeted-probe-educate-tpe.

Palmetto GBA: The Part B MAC indicated a Sept. 1 start date, too, but also referred to past reviews. “TPE cases that remained open during the Public Health Emergency (PHE) have been closed,” Palmetto said in an Aug. 31 update. Review the Part B MAC’s update and resources at www.palmettogba.com/palmetto/jjb.nsf/DID/ASNPH36180.

CGS: Part B MAC CGS joined Palmetto and WPS in announcing TPE’s resumption. CGS also confirmed a Sept. 1 start date, even though its announcement posted to its website on Sept. 2. “Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment” for TPE review, the MAC said. CGS also refers providers to its “Medical Review Activity Log” webpage where it lists both active and pending reviews. “Previous postpayment service-specific reviews will be phased out,” the Part B MAC added.

See CGS’ alert at www.cgsmedicare.com/partb/pubs/news/2021/09/cope23220.html.

Noridian: According to Noridian Healthcare Solutions, “several webinars to review the TPE process will be held over the next few months,” and providers should check Noridian’s webinar schedule for details, the Part B MAC mentioned in a Sept. 8 release. Peruse Noridian’s release https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/targeted-probe-and-educate-tpe-resumption.

NGS: The Part B MAC added its own spin on the TPE reup, too. “Effective 9/1/2021, the National Government Services Medical Review Department will discontinue sending postpayment ADRs and will resume reviews conducted under the TPE Medical Review Strategy,” NGS said in its online guidance updated on Sept. 9. “Providers should continue responding to postpayment ADR requests already issued.” Check out NGS’ alert at www.ngsmedicare.com/web/ngs/news-article-details.

FSCO and Novitas: At press time, Novitas Solutions and FSCO had not offered any TPE updates, but both Part B MACs do list several service specific topics that are actively being reviewed. Find Novitas active reviews at www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00184111 and FSCO’s list at https://medicare.fcso.com/Medical_review/0470098.asp.

Don’t Forget About What TPE Reviews Entail

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. However, “the review may be discontinued if appropriate improvement and an error rate below the target threshold is achieved during the review process,” CGS reminds.

The MACs “will send a notification letter to providers ... that have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information,” Palmetto explains.

After being notified, you can expect additional documentation requests (ADRs) from your respective MAC for the claims selected for review. You’ll have 45 days to respond to the ADR.

But: However, if your practice is struggling due to COVID restraints, there is some leeway. “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.”