CMS Targeted Probe and Educate Audit Program

By Jeanne A. Gilreath, CHBME, Senior Vice President and Chief Compliance Officer

One of the many programs CMS has implemented to help providers identify billing issues is the Targeted Probe and Educate (TPE) audit program.   It is designed to identify providers with high denial rates or unusual billing practices according to CMS.  If a provider is chosen for the program, the goal is to help the provider quickly improve.   The process is designed to identify common errors in a provider’s submissions and help the provider correct them.

The notices will come in a letter format from the provider’s Medicare Administrative Contractor (MAC), e.g., First Coast, NGS, Novitas, WPS, Palmetto, CGS, Noridian.

When performing medical review as part of a TPE, the local Medicare MAC focuses on a specific provider who has a particular item or service with the highest claim denial rates or billing practices that vary significantly from his/her peers.

The sample size is 20-40 claims that are intended to allow the local MAC to review enough claims to be representative of how accurately the provider documents with the necessary supporting documentation to meet Medicare rules and requirements while not being overly burdensome.

A provider can experience up to three (3) rounds of medical review.   At the conclusion of each round, the provider will be sent a letter detailing the results of the reviews and will be offered a one-on-one education session.  The education session in each round is developed based upon the review findings from the most recently completed round.    It is important to note that the determination of whether a provider moves on to additional rounds, e.g. Round 2 or Round 3, is based upon improvement from round to round, with education being provided during and after each round in order to help the provider throughout the process.

If after Round 1, the provider is compliant then the provider will not be reviewed again for at least one year on the selected services.    If some claims are denied, then the provider will be invited to a one-on-one education session.    The provider will be given 45-days to make changes and improve, before a Round 2 review of 20-40 claims and supporting medical records is requested in a second letter to the provider.     Any problems that fail to improve after three rounds of education sessions will be referred to CMS for next steps.   These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor or other action.

Finally, it is critical to take every audit request seriously including CMS RA program (Recovery Auditor) and SMRC (Supplemental Medical Review Contractor) audit requests.

Jeanne A. Gilreath, CHBME, Senior Vice President and Chief Compliance Officer

Ms. Gilreath has more than thirty years’ experience in the healthcare industry. At AdvantEdge, she is the Compliance Officer, reflecting ongoing industry changes and policy throughout AdvantEdge. She is also responsible for client development and expansion of value-added services to clients.

AdvantEdge Healthcare Solutions is a national top 10 medical billing company that provides billing, coding, and revenue cycle management solutions for specialty medical groups since 1967.   If you have questions about how AdvantEdge can improve your practice billing and coding to collect every dollar that you’re legally and ethically entitled, please call us at 877-501-1611 or email info@ahsrcm.com.

AdvantEdge