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CMS is on a never-ending quest to minimize inappropriate payments to providers.

 

Providers should take time to understand the conditions of participation they became subject to when they agreed to become providers for CMS beneficiaries. Providers should also understand that the third party administrators (FIs) also have conditions that they must follow in order to remain eligible to operate as Medicare contractors – and that outreach/education to providers is one of these requirements.

If a concern related to a Medicare “rule” is identified internally, it is not wise to ignore the issue. Self-reporting of potential issues with a request for provider education is generally well received by the Contractors (and much more so than when providers either buried or were unaware of compliance issues). When problems get identified via MAC audit/probe/etc., the Contractors tend to be less benevolent in how they manage the matter.

Here are answers to questions we are frequently asked about the Targeted Probe and Educate (TPE) initiative:

 

Q: How does the TPE process work?

 

A: CMS relies on Medicare Administrative Contractors (MACs) to review clinical documentation in order to prevent improper payments. MACs choose claims for review based on many factors such as the service specific improper payment rate, data analysis, and billing patterns of providers.

No matter how large or how small, no Medicare provider is immune to scrutiny, but providers CAN take steps to mitigate their risk exposure. (The details of which would be specific to each provider’s situation. Our team would be happy to speak with you about your unique circumstance.)

The flow diagram below provides an overview of what providers can expect to occur through the Targeted Probe and Educate (TPE) initiative:

TPE Process

Q: How will providers/suppliers be notified if they are included in the TPE process? 

 

A: Providers/suppliers who are included in the TPE review process will be notified via letter from their MAC. Notification letters will include details regarding the program and topic of review and why the provider has been selected for TPE.

 

Q: How are providers/suppliers identified for review? 

 

A: MACs will focus only on providers/suppliers who have the highest claim denial rates or who have billing practices that vary significantly from their peers. These providers/suppliers and specific services/items are identified by the MAC through data analysis.

 

Q: What happens if there are errors in the claims reviewed?

 

A: At the conclusion of each round of 20-40 claim reviews, providers/suppliers will be sent a letter detailing the results of the reviews and offering a 1-on-1 education session. MACs will also educate providers/suppliers throughout the TPE review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process. CMS’ experience has shown that this education process is well received by providers/suppliers and helps to prevent future errors.

 

Q: What should a provider/supplier expect during a 1-on-1 education session?

 

A: During a one 1-on-1 education session (usually held via teleconference or webinar), the MAC provider outreach and education staff will walk through any errors in the provider/supplier’s 20-40 reviewed claims. Providers/suppliers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed.

 

Q: Can claims reviewed as part of the TPE process be appealed? If a claim is appealed and overturned, would this impact the provider denial rate?

 

A: The appeals process is unchanged under the TPE process. If a claim denial is appealed and overturned, this would result in an adjusted denial rate for the effected TPE round.


 

If you have questions about your specific situation, contact Rich Klemmer, PT, MBA, & Director of Corporate Compliance at Therapy Management, Inc. Our company is vigilant about compliance and here to help your organization understand how to mitigate risks, respond to ADRs, and provide the highest level of person-centered care.