The Centers for Medicare & Medicaid Services (CMS) implemented the policy for expanding the Targeted Probe and Educate (TPE) review process for all Medicare Administrative Contractors (MAC) on October 1, 2017. The TPE process began as a pilot program in 2014–2015 for inpatient hospital status cases to improve provider outcomes in the review process and reduce improper claim payments. The CMS found the TPE process improved communication between the MAC and provider. Providers showed an increased understanding of regulations related to denials using the TPE process.
In previous probe review strategies, the CMS chose the topic for review, rather than the MAC, and all providers who billed the chosen topic were reviewed. With the TPE process, the MAC will identify the topic and providers who have the highest claim denial rates or billing practices that vary from their peers using data analysis, Comprehensive Error Rate Testing results and top 10 billing errors. The TPE process will replace all current medical reviews. Providers under current medical record or probe reviews will receive a letter informing them if the review has been discontinued, will continue or has been converted to a TPE review.
The TPE process includes three rounds of prepayment or postpayment probe reviews with education—see the TPE Flow Chart. TPE sample size will be between 20 and 40 claims. A nurse from the MAC will call the provider prior to the probe to confirm the facility contact person. The nurse will be the provider’s point of contact throughout the TPE process and will notify the provider of easily resolved errors that are identified. It’s important all providers have correct contact information in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) for this reason. Providers will continue to receive notification of medical reviews either by letter or Fiscal Intermediary Standard System (FISS). A new FISS reason code for TPE/additional documentation requests (ADR) will begin with “5TPE.” Providers will receive a letter of the review results for all claims at each round’s conclusion. Each individual claim result will be available in FISS Direct Data Entry as the claim is reviewed. The appeal process for a claim denial hasn’t changed, and the provider denial rate is adjusted for the affected round if an appeal is overturned.
After each round of reviews, the results letter will offer education on a one-on-one basis. The educational session will be through webinar or teleconference. During the educational session, the MAC outreach and education staff will go over any errors found in the 20 to 40 claims reviewed. The session will allow providers an opportunity to ask questions about the claim results and applicable CMS policies.
The subsequent rounds will be determined by the MAC based on error rates and are approximately six to eight weeks after the one-on-one education to allow providers time to make changes to improve their billing practices.
Providers that show significant improvement or compliance will be released from that particular topic and won’t proceed to the next round. That doesn’t mean a provider can’t be selected for a new TPE under a different topic.
If high denial rates continue after the three rounds of reviews, the MAC will notify the CMS. The CMS will decide how to proceed, which may include extrapolation, referral to the Unified Program Integrity Contractor and/or referral to the Recovery Audit Contractor.
Providers need to be aware of the changes in the medical review process and review all contact information for accuracy. Be sure to educate office and medical records staff to be alert for calls or letters regarding the TPE process.
Contact your trusted BKD advisor with questions or for more information.