Medicare Compliance & Reimbursement

“Each MAC independently determines the areas that are vulnerable for improper payments in their MAC — and they also get to determine the scope,” Shickle-Cline warned. Additionally, the MACs also decide “the claim error rate they’re going to allow for providers to reach their goals to be let off of the Targeted Probe and Educate [list].” In that regard, the MACs have a lot of power over who gets targeted and what kinds of claims they’ll review, she said.

Becoming familiar with your MAC’s TPE active and completed probes can really help you plan your claims compliance plan and follow through on fixing issues. “Some of the MACs — and I’ve seen quite a few of them — actually put out a notice of what they’re looking at, what’s on their radar, [and] what they’re going to be targeting docs for,” Shickle-Cline observed. “And that can be super helpful to our practices, knowing what is on the radar and what’s coming down the pike,” she acknowledged.

Here’s What to Expect With a TPE Review

Remember, you can be targeted either analytically through data mining or by referral for the first round of audits, reminded Shickle-Cline. After you receive a letter noting that you’re under TPE review, the audit process begins.

First, your MAC will pull a sample, which is usually 20 to 40 claims for a specific item or service. This is intended to be representative of your practice but not overly burdensome for your team to compile the necessary documentation attached to the pulled claims. You must reply to your MAC’s documentation requests within 35 to 40 days, but know, too, that failure to respond is counted as an error and impacts your overall payment rate.

Construct: If your MAC finds errors in this sample size, they may reach out to arrange provider education, attendance of which can include clinical, billing, and finance staff, as well as

anyone else for whom such an educational opportunity might be beneficial. This one-on-one education session is usually held via teleconference and might focus on the denials identified during the review process while provider education is constructed specifically for each provider, said Robin Peterson, CPC, CPMA, in a AAPC AUDITCON 2023 presentation, “How to Prepare for TPE Audits.” Providers can ask questions about their claims and/or relevant policies, and then have 45 days to incorporate the recommended changes before a second round of review is conducted to evaluate improvement.

Timeline: Typically, there are three rounds; however, the MACs say “they [could] discontinue the process if and when providers or suppliers become compliant,” Shickle-Cline said. Yet, that is rarely the case. “We work with providers and clients on these types of reviews all the time, I have never had a client who did not go the three rounds, who was let off successfully, like in any of these rounds,” she noted.

Important: Even if you do manage to make it successfully through the three rounds and get off TPE, you’re still going to be in a “holding pattern for about a year, and [your MAC] is also [going] to continue to monitor your claims data,” advised Shickle-Cline.

Understand What’s at Stake in the Aftermath

Having strong policies in place that include a communication chain of command is critical. Responding to your MAC’s request for documentation in the initial rounds, both thoroughly and quickly, can make or break your results and impact your relationship with auditors.

For example, if the MAC is looking through your records and asks for additional information, they may see that your problem is easily curable and they just need more supporting data to complete the TPE audit. If they are going to give you the opportunity, send in everything, Shickle-Cline counseled. “Make sure whoever you are assigning to send the records” knows about the various secure ways to submit to the MACs and “get out in front of these things early on,” she added.

The responders must include all the data on the reviewed claims because auditors may already have surmised what information is missing from the original file you’ve submitted. So, “if you’re pulling a note — but there’s more information stored in other parts of your EMR” and they ask for “XYZ,” you need to send it, she urged.

TPE failures can lead to long-term problems, too, Shickle-Cline suggested. If improvement benchmarks aren’t met and you don’t meet the ADR demands, your practice may face other forms of evaluation, like 100 percent prepay review, extrapolation (a calculation of overpayment estimate using statistical formulas, according to MAC Noridian), or referral to a Recovery Administrative Contractor (RAC) or a Unified Program Integrity Contractor (UPIC).

For example, if you get put on 100 percent prepay review, that can cripple a smaller practice. It means that every claim you submit must be accompanied by additional documentation, every time. That’s both a time constraint on your staff and cash flow killer for your practice, she said.

Pocket These 5 Tips on TPE Reviews

As you update your practice compliance plan, don’t forget to take into account potential Targeted Probe and Educate (TPE) claim reviews, suggested Alicia Shickle-Cline, AHFI, CHC, CPCO, CPMA, CRC, during AAPC’s HEALTHCON 2024 session, “Deep Dive into Targeted Probe and Educate.”

Consider adding these five TPE-centered actions to your to-do list

• Address claims issues before they start with benchmarking and annual internal audits.
• Put an internal process in place for communicating with your Medicare Administrative Contractor (MAC), which includes following the MAC’s required modus of communication (i.e. portal, email, EHR), so that you don’t miss critical requests.
• Utilize educational opportunities from your MAC to ensure you know coding and regulatory updates.
• Understand the plethora of risk factors that contribute to items and services being labeled medically unnecessary by CMS and your MAC.
• Follow through on all documentation requests in a timely manner.

If you still can’t meet the auditors’ demands, the following could occur:

• Your Medicare enrollment credentials could be revoked, and you would lose all billing privileges.
• CMS could add you to its preclusion list, which means you can’t get paid for services or items rendered under Medicare Advantage or Part D. “In 2022, they expanded the preclusion list from 3 to 10 years,” Shickle-Cline noted.
• You could be excluded from participation in all federal healthcare programs by the HHS Office of Inspector General (OIG).

Bottom line: Getting dismissed from the various Medicare programs from a TPE audit doesn’t happen often, but it is a possibility that should factor into your compliance plans. Here’s why: “Most providers that I know and that I work with, when they get a letter of revocation, basically, it’s like a death card to a lot of providers, who can’t participate in Medicare financially. That’s a big blow to their practices.”