The Centers for Medicare and Medicaid (CMS) has designed the Targeted Probe and Educate (TPE) program to help providers and suppliers reduce claim denials and appeals by providing one-on-one help. These reviews should be taken seriously. If compliance is not obtained by the end of the review process, there could be severe penalties that could include the loss of Medicare billing privileges.
During these TPE audits, Medicare Administrative Contractors (MACs) will be focusing on providers and suppliers that have the highest claim denial rates or have a significant difference in their billing practices compared to their peers. MACs will select between 20 and 40 claims to review, while providing education during the claims review process and after the probe review. After the education is finished, the provider/supplier will have 45 days to correct all of the identified errors.
According to CMS, providers that have claims compliant with Medicare policy will not be chosen to participate in a TPE audit. Some of these claims errors include the physician not including their signature, documentation not meeting medical necessity, encounter notes not supporting all elements of eligibility and having missing or incomplete initial certifications or re-certifications.
After the initial claims review, if the claims selected are in compliance, the provider/supplier will not be reviewed again for at least one year on the topic that was selected. If after the review of the corrections, the provider/supplier has not improved accuracy, then that provider/supplier with forego another session of education with the MACs. A provider/supplier going through the TPE audit process can complete three rounds of education before they will be given further actions by CMS.
This process is based solely on the MACs discretion.“MACs determine which providers/suppliers to target, whether claims meet coverage requirements, what error rate is considered compliant, and when a provider/supplier should be removed from TPE”. Future audits can be determined before the provider/supplier has had the opportunity to challenge claim denials. In other words, if a provider/supplier was selected to proceed with future TPE audits, then they would still have to complete these audits even if the claim denial was overturned, after being challenged.
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