Medicare Compliance & Reimbursement

All MACs will now perform Targeted Probe and Educate audits.

With assurances to decrease Medicare providers’ administrative burdens, CMS has made good on its promise. But for those whose claims are often found in error, the paperwork may be the least of your concerns.

Background: CMS decided over the summer to update its successful Probe and Educate medical review program, originally initiated in 2014. This past June, the agency upped its strategies, using first one of its Medicare Administrative Contractors (MACs) as a “pilot” for a more focused claims review process called Targeted Probe and Educate (TPE). Then in July, it added three more MACs to the preliminary lineup.

Now: Due to the success of the TPE pilot program, CMS decided to have all MACs utilize the review system. On Oct. 1, they will start pulling “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,” noted CMS in its online TPE guidance. Providers and suppliers with outlier tendencies who have claims errors and billing rates “significantly” outside the norm will be the primary targets.

“When performing medical review as part of TPE, MACs focus on specific providers/suppliers within the service rather than all provider/supplier’s billing a particular service,” CMS indicated. Since this type of scrutiny punishes the wrongdoer, clinicians and suppliers, who regularly submit correct claims, should see some administrative relief. “The purpose of this expansion is to reduce appeals, decrease provider burden, and improve the medical review and education process,” explained MAC NGS Medicare on its website.

How Will the TPE Process Work?

Under TPE, MAC medical reviewers will conduct three rounds of review, selecting 20 to 40 claims per round. As the program’s name suggests, the review will target certain at-risk providers, but so far CMS and the MACs have been tight-lipped about what the threshold for inclusion will be. And according to online insight, the MACs will decide the topics for review.

“If high denial rates continue after three rounds, the MAC shall refer to CMS for additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the RAC, 100% pre-pay review,” CMS warns in the Medicare CR 10249.

Relief and reward: For many Medicare providers, the change in claims review tactics comes as a relief after years of scrutiny. “The ‘targeted’ areas will reduce the chance that compliant billers would normally be subject to an audit,” notes Baltimore attorney Christopher P. Dean, Esq. in online analysis for Baker Donelson. The smaller claims selection reviewed “will reduce the administrative burden compared to the larger audits in the past,” he suggests.

The new TPE plan is “an affirmative approach to resolving erroneous claims — rather than pursue past claims with a perceived zeal for recoupment of incorrect (or worse, false) claims that could be extrapolated,” Dean says.

Resources: For the CMS fact sheet on the Targeted Probe and Educate expansion, visit www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.

Read the Medicare CR 10249 on the TPE ramp-up at: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf.