Practice Management Alert

Don’t risk making these common errors.

The Centers for Medicare & Medicaid Services (CMS) is increasing scrutiny on some practices and providers with high claim submission error rates through Targeted Probe and Educate (TPE) audits.

“The good news is that most providers will never need a TPE. A TPE is intended to increase accuracy in very specific areas,” said Amy Pritchett, CPC, CPCO, CDEI, CDEO, CPMA, CRC, CANPC, CASCC, CEDC, Approved-Instructor/Manager at HCC Coding/Audit and Education Services and Pinnacle Enterprise Risk Consulting Services, in a AAPC AUDITCON 2023 presentation, “How to Prepare for TPE Audits.”

Find out what you can do to prepare for a TPE audit — while hoping you’ll never need to experience one.

Understand TPE Aims

CMS says the TPE program is designed to help providers improve their claims submission process quickly through one-on-one help from Medicare Administrative Contractors (MACs). CMS says that most errors are simple, like the absence of physician signatures or illegible writing on records. A TPE audit may focus on a provider’s claims submission process or workflow to identify repetitive errors.

CMS says that the majority of the providers who participate in the TPE program improve the accuracy of their claims, and those who do not manage to increase successful claim submission after three rounds of education sessions are referred to CMS for other forms of review, like 100 percent prepay review.

“MACs use data analysis to identify providers or supplies with a high claim error rate, that have unusual billing practices compared to their peers in the same specialty, or they bill items or services that have high national error rates, or financial risk,” said Robin Peterson, CPC, CPMA, in the same presentation.

Expect These TPE Phases

A TPE audit begins with an advanced documentation request (ADR), which will identify the reason for the review and the claims that need supporting documentation, Peterson said. The sample size is usually 20-40 claims, which is intended to be representative of a provider’s practices but not overly burdensome. Providers should reply with the requested documentation in 35-40 days and know that failure to respond is counted as an error and impacts overall payment rate.

If the 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, Peterson said, and might focus on the denials identified during the MAC review process; provider education is constructed specifically for each provider. 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.

If improvement benchmarks aren’t met, providers 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).

“Providers whose claims are compliant with Medicare policy won’t be chosen for a TPE,” Peterson said.

If you do receive an ADR, make sure you provide all of the documentation requested and review all of the documents as you compile them, and return everything within 45 days — they recommend 30-45 days, Peterson said.

Top tip: Peterson listed some “don’ts” to keep in mind if you ever need to respond to an ADR:

• Don’t bind records together.
• Don’t highlight records.
• Don’t attach sticky notes or tabs.
• Don’t alter or change records — but MACs do recommend changing the document to portable document format (PDF).

You can mail or fax the records to your respective MAC.

Providers who are found to be compliant won’t be reviewed again for at least one year on that particular topic, she noted.

If issues persist, especially with overpayment, the consequences can be severe. CMS can halt a provider’s Medicare payments, and investigations can lead to civil or criminal charges being filed against the provider for healthcare fraud, Peterson said.

Prepare and Stay Aware

For most providers, neither a TPE nor an ADR is a foregone conclusion. There are steps you can take to bolster your coding practices and claims submissions process, which can help remove you from the crosshairs of a TPE.

First, you should make sure you stay up to date with coding requirements, which for Medicare providers, means looking to your respective Local Coverage Determinations (LCDs) and communicating updates with the administrators and billers in your practice. Creating internal policies and procedures that encourage this sort of checking in can cement a best practice. Keep a look out for any notices, so you remain compliant with the necessary timeline.

Next, Peterson also recommends making some delegation decisions surrounding TPE audits. Select appropriate staff to form a TPE audit response team and designate a main point of contact. Once you have your TPE-centered team, you can focus on creating or gathering training and education resources, and then making sure relevant team members get the education they need to be able to navigate the TPE process. “Require written acknowledgement from staff when training is complete,” she recommended.

Peterson explained that different MACs have different policies and procedures, as well as different ways they want providers to submit documentation or other information. Once you have a TPE point person, that person can do the nitty-gritty work of finding out the particulars for your respective MAC, which can help your claims submission process overall and cut out a lot of the guesswork if you do receive an ADR.

Another avenue that might be helpful is engaging an outside attorney or consultant to provide guidance on the audit process and help you prepare a response, Peterson said.

“Attorneys or consultants can also assist in conducting a self-audit and ensuring compliance, to prevent future TPE audits. Billing and coding consultants can identify and prioritize areas for compliance, auditing, and monitoring, to prevent future audit requests, as well as solutions tailored to your situation or practice,” she said.

Conducting routine internal compliance audits can help practices detect any issues before they are noticed by CMS (or other payers or investigators). Even checklists can help a practice make sure they’ve dotted their i’s and crossed their t’s for each claim — especially because a lot of claim errors can be as simple as the absence of a physician’s signature.