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MEDICARE TPE AUDITS - TARGETED PROBE AND EDUCATE (SUMMARY)
Over the past 30 years, Jackson Davis Healthcare professionals have worked side-by-side with healthcare providers to build winning responses to a full range of "Probe and Educate" initiatives undertaken by CMS. NOTHING is better than responding to a TPE audit with a comprehensive, rock-solid audit defense. Jackson Davis has assisted 100s providers nationwide in building winning responses to Probe and Educate requests, ADR responses and 10,000+ TPE audit appeals, UPIC audit appeals, RAC audit appeals, ZPIC audit appeals and a host of others. We have helped build Medicare & Medicaid audit defense cases for the best providers nationwide. We have defended innocent providers facing fraud allegations from ZPIC auditors, the Office of Inspector General and the U.S. Attorney. No one will work harder or give you a better chance to win than Jackson Davis… and we prove it every single day!
Our professionals have successfully responded to Probe and Educate requests and challenged Medicare audit results through every step of the Medicare appeals process - our record and reputation is unparalleled. Time and again, we have assisted providers in building solid TPE, UPIC & RAC audit defense cases for Redetermination / Reconsideration and successfully defended providers at ALJ hearings. We are a passionate provider advocate and believe 100% that Medicare & Medicaid coverage criteria rules-the-day. Our success fully encompasses healthcare providers across the U.S. and includes: hospitals & integrated delivery systems, hospices, home health agencies, inpatient rehab facilities, skilled nursing facilities, physician practices, DME providers and physical therapists.
The Centers for Medicare & Medicaid Services (CMS) utilizes Medicare Administrative Contractors (MAC) to review clinical documentation and identify possible overpayments. Much like the CMS contracts with both UPIC and RAC auditors, MACs choose claims for review based on many factors such as the service specific improper payment rate, data analysis and billing patterns of the provider.
In 2014, CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy, Probe and Educate. CMS believes results of this program have been favorable, based on the decrease in the number of claim errors after providers received education. CMS is now changing this strategy by moving from a broad Probe and Educate program to a more targeted one. When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. CMS intends the term "TPE" to convey that the number of claims reviewed is relatively small in comparison with previous provider specific review where the number of claims reviewed for an individual provider may have been much larger. After each round of TPE audits, providers are offered individualized education based on the results of their reviews. This program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017. As a result of the outcomes demonstrated during the pilot, including an increase of provider education as well as a decrease in TPE audit appeals, CMS has decided to expand to all MAC jurisdictions late in 2017.
Selection of TPE Audit Claims
The MACs will select TPE audit claims for items/services that CMS believes pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate (again, very similar to UPIC audits and RAC audits). MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. Those providers/suppliers and specific items/services will be identified by the MAC through data analysis. TPE audit claim selection is different from that of previous probe and educate programs. Whereas previously the first round of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset. This eliminates the auditing of providers who, based on CMS data analysis, are already submitting claims that appear to be compliant with Medicare coverage criteria.
TPE Probe Audits and Education Process
The TPE audit and education process includes a review of 20-40 claims followed by one-on-one, provider-specific, education to address any errors with in the provider’s audited claims. Providers/suppliers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 claim audits, followed by additional, provider specific, one-on-one education. Providers/suppliers with high error rates after round two of TPE audits will continue to a third and final round of probe reviews and education (Please see the TPE Process Flowchart in the downloads section below). In addition to education at the conclusion of each 20-40 claim probe audit, MACs also educate providers throughout the TPE auditing process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.
Providers/suppliers with continued high error rates after three rounds of TPE audits may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a UPIC auditor / RAC Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.
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The Centers for Medicare & Medicaid Services (CMS) utilizes Medicare Administrative Contractors (MAC) to perform select Medicare audits and to analyze clinical documentation for a broad range of Medicare claims under review. In 2014 (in addition to ongoing RAC audits and the more recent roll-out of the UPIC audit program nationwide), CMS began a program - called "Probe and Educate". This more limited-scope audit combined a review of a sample of Medicare claims with education in an effort to further reduce errors in the claims submission process. In October of 2017, CMS elected to expand this effort from a limited Probe and Educate program to a more nationally-focused one - Targeted Probe and Educate or "TPE".
When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus efforts on SPECIFIC (or "targeted") providers/suppliers within the service rather than ALL provider/suppliers billing a particular service. TPE audits typically involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. "TPE" is intended to convey that the number of claims reviewed is relatively small in comparison with previous provider specific review where the number of claims reviewed for an individual provider may have been much larger (i.e. RAC audits, UPIC audits, etc.). After each round, providers are offered individualized education based on the results of their reviews. This program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017. CMS decided to expand to all MAC jurisdictions in late 2017.
MEDICARE TPE AUDITS - TARGETED PROBE AND EDUCATE (DETAILED STRATEGY)
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