Pathology/Lab Coding Alert

Hint: Look at your MAC’s focus to troubleshoot internal issues.

These fundamentals are key to balancing the logistics of a TPE review, according to Alicia Shickle-Cline, AHFI, CHC, CPCO, CPMA, CRC, during AAPC’s HEALTHCON 2024 session, “Deep Dive into Targeted Probe and Educate.”

Here’s why: “The perception behind these TPE audits is that they are educational audits; [however] after the third round, there are some pretty significant ramifications for providers, suppliers, and organizations,” cautioned Shickle-Cline. “TPE is geared toward looking for specific issues … and they’re targeted toward certain providers who have a high claim error rate or show analytically unusual billing practices for items and services,” she maintained.

Moreover, those issues can put both a physical and financial strain on your lab. That’s why it’s essential to plan ahead for a possible TPE audit scenario before you’re in the throes of one. At the top of your worksheet should be figuring out what your Medicare Administrative Contractor (MAC) has on its active review list and cross checking that with your persnickety in-house and outlier issues, which can help reduce your chances of a future claims review in the first place.

Read on for an overview of the TPE process, what to expect, and what might come after an audit.

Factor In This Important Audit Point

You might think the Centers for Medicare & Medicaid Services (CMS) holds all the cards on Medicare claim reviews, but with TPE that’s not the case.

“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 lab 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 education, 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.” Labs 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 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 lab 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).