Medicare Compliance & Reimbursement

Question: Is there a specific denial percentage for a service that Medicare looks for when determining whether a provider will be part of a Targeted Probe and Educate (TPE) review?

Iowa Subscriber

Answer: No, not exactly. Though you might think that outlier behavior alone would alert your Medicare Administrative Contractor (MAC) to claims issues, it’s more complicated than that, according to the Centers for Medicare & Medicaid Services (CMS). In fact, it’s a combination of factors from high denial rates, to type of service, and even jurisdiction requirements.

“The error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review,” CMS says in a TPE question-and-answer set. “The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC.”

Reminder: After Round 1 of TPE review, providers are offered education to help with their noncompliance. If they continue to have a high payment error rate above 15 percent, then they can expect another probe — and subsequent education, suggests Part B MAC National Government Services (NGS) in online guidance.

If a provider cannot meet the necessary compliance standards after three rounds, “CMS may instruct the MAC to take additional action which may include: extrapolation; referral to UPIC; referral to the Recovery Audit Contractor; or 100 percent prepay review,” NGS says.