Targeted Probe and Educate Review: The Kind of Healthcare Audit That Can Help — Not Hurt — Your Practice

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By Working with and Learning from the MAC Healthcare Auditor, Your Health Care Entity or Medical Supplier Group Can Immediately Fix Claims Errors and Stay on the Right Side of CMS

Getting a letter that says your healthcare practice or medical supplier business must undergo a Medicare Administrative Contractor (MAC) healthcare audit is never good news. But if the letter indicates the review is part of the Targeted Probe and Educate Program (TPE), your practice may actually benefit from it.

Administered by the Centers for Medicare and Medicaid Services (CMS), the TPE works to detect the kinds of claims submission errors that would bring severe financial risk to the Medicare program. It’s done through a different kind of MAC audit, though: instead of reprimanding your organization for non-compliance, the MAC provides one-on-one educational sessions about how to fix the error(s) in question.

That’s where the “Educate” part of TPE comes in, as CMS’s goal is to help providers avoid RAC audits by way of direct learning and correction. Thus, when you have immediate knowledge of what your healthcare entity must correct based on this review, you can then make sure organization’s compliance program and corrective action plan follows through on it.

Here’s what you need to know about the TPE program, how to respond should that letter arrive, and the dangers of not complying with the process.

What is the Purpose of the TPE Program?

The TPE program helps healthcare providers and medical suppliers identify errors made in the claims submission process, then, through immediate follow-up education, make prompt improvements and help reduce future claims submission errors. CMS put the program into full effect in October 2017, following more than a year in pilot phase.

Who Do the MACs Target for TPEs?

The MACs’ targets for TPEs are healthcare providers and medical suppliers that have high claim error rates; have a history of Additional Documentation Requests (ADRs) denials; and/or follow billing practices that differ significantly from similar healthcare entities. In addition, MACs will look at healthcare agencies that provide the kinds of items and services that have high overall national error rates and are a financial risk to Medicare.

Should I Be Worried That My Healthcare Practice Might Be Targeted for a TPE?

If your healthcare practice or medical supplier’s claims submission process is compliant with Medicare policy, you should not be concerned about being chosen for TPE. CMS’s goal with TPE is to concentrate solely on providers and suppliers that, based on data analysis, have the highest claims error rates or employ billing practices that would designate them as outliers.

What Are Some of the More Common Claim Errors Noted with TPEs?

    • The certifying physician’s signature was not included.
    • The documentation in question does not meet medical necessity.
    • The included encounter notes do not support all elements of eligibility.
    • Initial certifications and/or recertifications are missing or incomplete.

Is It Possible That My Healthcare Practice Could Be Subject to Multiple Reviews at a Single Time?

Yes. A MAC can conduct TPEs for healthcare providers and medical suppliers that have more than one questionable item or service that meets the error criteria. Also, if an organization has multiple National Provider Identifiers (NPIs), each NPI may be subject to a TPE review.

How Does the TPE Process Go?

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.

What Error Percentage Does the MAC Consider to Be a ‘High Denial Rate’? And What Other Factors Determine Whether My Organization Needs Additional Review?

The error percentage varies, as it is based on the service and/or item under review. CMS notes that “the Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC.”

Other factors that determine the need for additional review “may include, but are not limited to, decrease in error rate with each round, as well as participation in and improvement with education.”

What Happens If My Practice Fails All Three TPE Rounds?

Your organization will be referred to CMS for the necessary next steps, which could include:

    • 100% pre-pay review
    • Referral to a recovery auditor (RAC, UPIC, ZPIC, etc.)
    • Extrapolation of error rates from a claims sample that could go back as far as six years
    • Possible Medicare exclusion
    • Referral to the OIG for further investigation
    • Placement on the CMS Preclusion List

Can Claims Reviewed as Part of the TPE Process Be Appealed? And If a Claim is Appealed and Overturned, Will This Impact the Provider Denial Rate?

The appeals process stays the same under the TPE review process, and should a claim denial be overturned, this would be taken into consideration in subsequent (if any) TPE rounds. But if the appeals results are not available at the time your organization progresses to a second or third TPE round, yet the results become available when your organization is referred to CMS, CMS will take those results into consideration as it determines the need for additional action.

Should your practice’s adjusted error rate indicate no need for additional review following the appeals process, CMS will make that recommendation. Your organization will then be monitored by the MAC as it would be had you passed the TPE process and been released from review.

What Can Chapman Law Group’s Healthcare Audit and Compliance Lawyers Do for My Practice for Matters Related to a TPE?

Should your healthcare practice or medical supplier organization be selected for a TPE, the healthcare compliance attorneys and healthcare audit lawyers at Chapman Law Group can advise you on best preparation practices.

If you have successfully completed the first round of TPE, our national health care compliance lawyers can work with you on developing a Corrective Action Plan (CAP) — or modifying your existing plan — to ensure proper monitoring, auditing, and compliance.

And, should your healthcare practice or medical supplier business be subject to a subsequent RAC, UPIC, ZPIC, or other recovery audit, our healthcare audit attorneys will be by your side.

At Chapman Law Group, we work with healthcare providers across the U.S. on compliance, auditing, and other regulatory healthcare matters, with four national offices to serve you:

Contact us today to learn more about our healthcare law services.

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Wedad Suleiman, LL.M.

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Healthcare Compliance, Civil Litigation

Michigan Office
1441 W. Long Lake Road, Suite 310
Troy, MI 48098
Phone: (248) 644-6326

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