Eli's Hospice Insider

Warning: Failing TPE can lead to RAC scrutiny or worse.

Now that Medicare had decided to apply Targeted Probe & Educate medical review to all of its provider types, you'd better get to know the program that cost you big in time and resources.

On its TPE webpage, the Centers for Medicare & Medicaid Services says the program:

• focuses on specific providers, selecting "claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate."
• reviews 20 to 40 claims per item or service, per round, for a total of up to three rounds.
• "After each round, providers are offered individualized education based on the results of their reviews," CMS says on its TPE website.
• MACs may "educate providers throughout the probe review process, when easily resolved errors are identified."
• After each round, the MAC has the opportunity to take you off TPE if you demonstrate "low error rates or sufficient improvement in error rates" (see story, p. 89, for details).
• "Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action," CMS says.

Reminder: If you are chosen for TPE inclusion, your MAC will review 20 to 40 claims per item or service, per round, for a total of up to three rounds of review, CMS explains on its TPE website. "After each round, providers are offered individualized education based on the results of their reviews."

MACs will prove one-on-one education after each round, but also may "educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process," CMS says.

The question of which providers will receive TPE attention initially remains unclear, however. MACs will "select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. These providers/suppliers and specific items/services are identified by the MAC through data analysis," CMS says.

TPE differs from the initial Home Health Probe & Educate program, which chose claims from every HHA in the nation in its first round. Instead of subjecting all hospices nationwide to TPE edits, targeting P&E review from the onset "eliminates burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy," according to CMS.

Timeline: TPE took effect Oct. 1, and targeted providers will receive a letter that will "outline the reason for selection and will provide an overview of the TPE process and contact information," MAC Palmetto GBA explains in a recent TPE article on its website.

Subsequent rounds of TPE will begin 45 to 56 days after individual provider education is completed, Palmetto adds.

Note: An NGS TPE presentation is at www.ngsmedicare.com/ngs/wcm/connect/813d9f1cb243-4295-a7e0-0826c26892f4/1928_0917+Targeted+Probe+and+Educate+TPE-09+28+2017_rev_508.pdf?MOD=AJPERES. A link to the Q&A set is on CMS's TPE webpage at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.