In June 2016, CMS began a pilot program in one MAC jurisdiction called Targeted Probe and Educate (TPE). This program is a medical review strategy that was intended to alleviate some of the burden for providers undergoing medical record review. In July 2017, CMS expanded the program to three (3) additional MAC jurisdictions. The pilot has been such a success that as of October 1, 2017, the program has been expanded to all MAC jurisdictions.
Rather than reviewing all providers for a particular service as has been the previous strategy for medical record review, under TPE MACs will select claims that have a high financial risk for Medicare or that nationally have a high error rate. The MACs will then focus only on those providers who have the highest error rates or whose billing practices designate them as outliers. The selection of specific claims/services and providers will be determined by detailed data analysis.
The TPE process will include an initial review of 20-40 claims. This will be followed by a targeted, one-to-one education program to address errors in the claims being reviewed. Those providers who continue to have high error rates will then have to proceed with a second round of reviewed claims and additional education. If after the second round, the provider continues to have high error rates they will continue to a third round of claims review and education. If after three rounds of TPE the provider continues to have high error rates, they will be referred to CMS for further action which could consist of prepay review; referral to ZPIC, UPIC or RAC; extrapolation to other claims, etc. However, it is important to note that the provider can be removed from the review process at any point if they sufficiently demonstrate a significant reduction in their error rate or low error rates. CMS has provided a process flow chart to outline how the TPE process works.
ACA members who receive notice of a TPE should contact ACA immediately by emailing Medicare@acatoday.org.
It is important to note the following:
- Providers who have been selected for TPE will receive a notification letter about the review and Additional Documentation Requests (ADRs) will be used to indicate which claims have been selected for the TPE.
- Records must be submitted promptly when requested, and it is highly recommended that providers respond to the ADR ASAP, and prior to the 45-day deadline specified.
- Not responding to the requests will count as an error (in other words, ignoring the requests is not an option - it will automatically place the provider into the next round of review, in essence expediting the process and denying the provider the education process and ability to correct any errors).
- The TPE process does not replace or change the appeal process. The one-on-one education sessions are not considered appeals and the result letters and education sessions do not extend the appeal period.
Medicare: Types of Audits and Records Requests
Medicare Audit/Record Request Tips
Medicare Part B Appeals
Medical Review and Education - TPE
Reducing Provider Burden
TPE Process Flow Chart