CMS Adopts National Targeted Probe and Educate Program

On October 1, 2017, the Centers for Medicare & Medicaid Services (“CMS”) implemented its national targeted probe and educate (“TPE”) program. TPE is designed to reduce improper payments by identifying providers/suppliers with high denial rates or unusual billing practices and providing education to correct non-compliance with claim submission criteria. However, repeated errors could potentially result in an elevated action, such as additional prepayment review, extrapolation or referral to the ZPIC/UPIC for example. Providers/suppliers should carefully review claims to ensure compliance with Medicare billing requirements as simple claim errors, such as a missing signature, could result in selection for the TPE process.

Background

CMS initially launched TPE as a pilot program in one Medicare Administrative Contractor (“MAC’) jurisdiction in June 2017 and later expanded the program to three other MACs in July 2017. Given the success of the pilot programs, CMS decided to expand TPE nationally in October 2017. The initial probe and educate programs included all providers/suppliers that billed a particular service chosen for review. In an effort to refine the program, CMS determined that efforts would be better directed toward those providers/suppliers who, based on data analysis, pose the most risk to the Medicare program. Under the national TPE program, each MAC will be responsible for implementing TPE in its jurisdiction, including the selection of the topic for review, as well as identifying providers/suppliers to participate in the program. The national expansion will comprise three rounds of prepayment probe review and subsequent education.

How Does TPE Work?

The MACs use data collection to identify providers/suppliers who have high claim error rates or unusual billing practices in comparison to their peers. Selected providers/suppliers will be subject to review of 20-40 claims and supporting medical record documentation. If compliant, the providers/suppliers claims will not be reviewed again for at least another year on the selected topic. If errors are identified, one-on-one education is provided and additional claims are then reviewed within 45 days to identify improvement. If errors continue after three rounds of review and education, the provider will be referred to CMS for possible further action. Such action may include 100 percent prepay review, extrapolation and/or referral to a Recovery Auditor. Providers/suppliers selected for TPE should keep in mind that they are not excluded from other MAC medical review activities, such as automated reviews and other pilot review programs as directed by CMS or reviews conducted by other CMS review contractors.

Practical Takeaways

Providers/suppliers should be cognizant of Medicare claims submission criteria as errors, such as missing physician signatures, insufficient documentation to support medical necessity or missing or incomplete certifications, could result in selection for TPE. Once providers/suppliers are selected for TPE, their claims will receive increased scrutiny until the accuracy of their claims improve through the course of the three-cycle review process or risk referral to CMS for further action. If you are selected for TPE, consider implementing corrective actions to help ensure timely improvement and discontinuation of participation in TPE for the next 12 months.

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