If your healthcare practice or medical supplier business is targeted for a TPE review, you will receive a Notice of Review letter that provides the reason why you’ve been placed on review. This begins the first of up to three rounds in the TPE process.
Your practice will then receive an ADR for anywhere between 20 and 40 claims; these claims make up the initial review. According to CMS:
“The 20-40 claim sample size is intended to allow the MACs to review enough claims to be representative of provider/supplier behavior. This allows MACs and to assess whether claims generally have the necessary supporting documentation to meet Medicare rules and requirements, while not being overly burdensome.”
You will have 45 days to respond to the ADR, and the MAC has 30 days to review the claims. Providers/suppliers will then be sent a letter detailing the results of the reviews.
If your claims are determined to be compliant and the assessment is considered below the 15% financial risk mark, your practice will not need to be reviewed for the error(s) in question for at least one year.
If your claims have an error percentage that is considered a “high denial rate” (see next section for more on this), you will be asked to attend a mandatory one-on-one education session (usually via webinar or teleconference) to review the area(s) that need(s) improvement.
In addition, MACs also educate providers/suppliers throughout the TPE review process, such as when errors that can be easily resolved are identified. This will help you and your organization in avoiding similar errors later in the process.
Once you’ve completed the one-on-one education session, you will have 45 days to make the changes discussed in the session. This is followed by a second round of 20-40 claims analysis, during which the MAC will review improvement your organization has made to its claims submission and billing practices. The MAC will then order a one-on-one education session (or sessions) as needed.
Should your practice fail in this second round, the MAC will order a third and final round of claims analysis, with necessary follow-up education sessions.
Note, however, that not responding to the initial ADR will count as an error, automatically placing your organization into the next round of review. If this happens, you will be denied the one-on-one education process and ability to correct any errors that would have come from that phase of review.