Medicare Compliance & Reimbursement

Be on top of your MAC's TPE guidance as the program evolves in 2018.

Now that the MACs are running the show for CMS's Targeted Probe and Educate (TPE) program, ensure you know what's on the to-do list for your jurisdiction.

Nuts and bolts: After conducting two rounds of regular Probe & Educate reviews focused on face-to-face requirements, the Centers for Medicare & Medicaid Services instructed all of its MACs to switch their entire medical review operations over to TPE in October (see Medicare Compliance and Reimbursement, Vol. 43, No. 19.). The success of the pilot program led to the current TPE process where MAC medical reviewers conduct three rounds of review, selecting 20 to 40 claims per round, targeting certain at-risk providers as opposed to looking at 100 percent of claims. The compliance initiative points to CMS's current mantra to reduce administrative burden for the majority instead focusing on outliers who need claims assistance.

Now: Medicare providers caught up in the first wave of TPE audits seem to be largely those that struggled under the previous Probe & Educate campaign focused on F2F, anecdotal evidence suggests. That's been the case so far for virtually all of the billing clients for BKD, reports BKD's M. Aaron Little in Springfield, Missouri.

About half of those agencies now under TPE landed there because they didn't respond to the P&E Additional Development Requests at all in the first two rounds, Little says. The other half submitted documentation, but failed the review for various reasons.

Justification: The MACs claim that "they target providers who have been noncompliant in the past," notes attorney Robert Markette Jr. with Hall Render in Indianapolis. But Markette suspects it's just an easy strategy to make larger recoupments.

Take These Measures To Tackle TPE

While it's too late to change how your practice fared under P&E, you can boost how you perform under TPE. Consider these steps to make sure you survive and thrive, even in the face of overwhelming amounts of review under the program:

Tip 1: Focus on your contact person. Finding out what you're doing wrong, so you can fix the problem before your next round of TPE, is essential. Remember, after three rounds of TPE, your MAC will refer you to the CMS for "additional action," notes HHH MAC CGS on its TPE website. That referral could have some drastic results. That "additional action ... may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action," CMS says on its TPE webpage.

So, "it is imperative when responding to the TPE [ADR] that you include the name and number of your designated contact person," stresses MAC Palmetto GBA in a Jan. 3 message to providers. "Our medical reviewer will contact your designated person prior to the conclusion of each TPE round to discuss the reviewsummary."

How it works: "When you respond to the ADR include the contact information in the cover letter," Palmetto says in a recent question-and answer set on TPE. "The same reviewer is reviewing that entire set of records and he or she will become accustomed to who that contact person is. Please make sure to include the contact name(s) and a correct phone number."

Pay attention: Providers seem to be having trouble with this critical requirement. "We are experiencing some trouble getting in touch with and finding the appropriate person," Palmetto says in the Q&A.

Tip 2: Management must step up. The 20 to 40 claims reviewed under TPE "is a lot of ADRs to manage in a short span of time," Little says. "There is a lot at stake, so make sure the management team is monitoring for any written correspondence notifying them of TPE," he advises.

Tip 3: Keep staff alert to TPE duties. Billing personnel should be "tuned in and know how to identify claims selected for ADRs," Little recommends. And prioritize making sure that "medical records/clinical personnel are prompt in compiling the documentation required for a timely ADR response."

Tip 4: Facilitate smooth submission of ADRs. Time is of the essence in submitting your documentation, since a high ADR nonresponse rate is a TPE topic that can put - or keep - you on the review list. "Take advantage of the MACs' electronic ADR submission," Little urges. "The general consensus seems to be that the most effective, direct method of responding is through the MACs' web portals": myCGS, Connex for National Government Services, and eServices for Palmetto GBA.

Tip 5: Dive into the TPE details. There's a lot to learn about the program, but it's important to know the facts. "The contractors determine where outliers occur and TPE is now based on that data," said NGS Medicare's Nathan L. Kennedy, Jr., CHC, CPC, CPB, CPPM, CPMA, CPC-I, AAPC I-10 Approved Trainer in a Jan. 24 webinar on the subject. Find out as much as you can about how TPE works, how the ADR-submissions process pans out, and what you can do to avoid future audits.

For example: Just because you get offered one-on-one education, doesn't mean you will be going on to the next round of the program. "We will be providing education to any provider that has any denials. If you have 40 samples and one claim is denied, we will be reaching out to provide education about why that one claim was denied," Palmetto explains in the Q&A. "But just because you had education given, does not mean that you will automatically progress to the next round. Our due diligence is to help you understand why that claim was denied and how to prevent that in future." Palmetto hasn't released figures on what denial rate will kick you up to the next round of TPE, but NGS has said it will use a 15 percent or higher benchmark.

6. Stay tuned. The TPE program is still evolving as it picks up steam. Stay alert to new details as they emerge from CMS and the MACs.