CMS Targeted Probe & Educate Policy Program for Audits
CMS (Centers for Medicare and Medicaid Services) has announced in August of 2017 that it will start a new national audit strategy titled Targeted Probe and Educate (TPE). CMS had pilot programs in TPE which demonstrated success and so the decision was made to use this audit process nationwide.
Medicare Administrative ContractorsCMS uses MAC (Medicare Administrative Contractors) to review clinical documentation to determine if improper payments have been made and to prevent reoccurrence. This process could lead to a provider/supplier being placed on a prepayment program which required that medical records be submitted with each claim. Generally, the prepayment process lasted 180 days but could be extended, dependent on the findings on claim reviews. The provider/supplier had long waiting periods to receive reimbursement under this type of pre-payment review.
CMS will not be doing prepayment reviews as it was done before. Now the MAC will do 3 rounds of Targeted Probe and Educate for specific providers/suppliers. The TPE will focus on one-to-one education throughout the process to improved identified error.
CMS has stated that the goal of TPE is to improve claims payment error rates and reduce the volume of appeals by using the process of targeted review and education.
ProcessA provider will have three rounds of review and education, if a high error rate persists, the MAC will refer the supplier to CMS for possible further action. The MAC will review 20-40 claims per provider, per round, per item or service for a total of up to three rounds of review. Each round of probe review will involve 20-40 claims followed by a round of provider specific education.
Provider/suppliers with high error rates after the second round will continue to a third and final round of probe review and education. Providers with high error rates after three rounds of TPE may be referred to CMS for additional action which could include 100% prepayment review, referral to a recovery auditor or other action.
If the providers/suppliers demonstrate a low error rate or sufficient improvement in error rates as determine by CMS they can be removed from the review process.
FutureTPE can be very useful to providers/suppliers as education on identified errors may lead to changes in the practice that will save time, resources, finances in complying with "traditional" prepayment reviews. Small practices have a difficult time keeping up with the multitude of changes and regulations under Medicare. Education was a missing component for many providers/suppliers. Likewise, the Medicare appeals process has been backlogged. A provider supplier many times continued the same activity because there had been no process of targeted education and information surrounding the identified errors in documentation or billing, or any other findings.