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Be aware and prepare for the Targeted Probe and Educate (TPE) review process

 

The goal of CMS's Targeted Probe and Educate program is to help providers and suppliers reduce claim denials and appeals through one-on-one help.[1]


Who will be chosen [1]

  • Providers and suppliers who have high claim error rates or unusual billing practices, and
  • Items and services that have high national error rates and are a financial risk to Medicare.

What are some common errors according to CMS [1]? 

  • The signature of the certifying physician was not included
  • Documentation does not meet medical necessity
  • Encounter note did not support all elements of eligibility
  • Missing or incomplete initial certifications or recertification

How does it work [1]

  • If chosen for the program, you will receive a letter from your Medicare Administrative Contractor (MAC).
  • Your MAC will review 20-40 of your claims and supporting medical records.  Once reviews begin, you will be notified of the selected claims per your normal Additional Documentation Request (ADR) process. This may be via a mailed ADR letter and/or Direct Data Entry (DDE). If some claims are denied, you'll be invited to a one-on-one education session to instruct you how to correct your records. You will be given at least 45 days to submit medical record information that supports the services billed. Before you send the requested records, some MACs (e.g, WPS GHA) suggest a clinician double-check the accuracy of your submitted claim.[2] 
  • The MAC will review the claim documentation after its receipt, according to CMS timelines, and will determine whether or not the submitted documentation meets the requirements. Along with the claim determination, the MAC will make a determination of liability for services and whether you are without fault for overpayments. Some MACs (e.g. WPS GHA) make individual claim result letters available via their Portal, along with general results of the Hyperbaric Oxygen Therapy review, following completion of the review process. If you have any questions, contact the Provider Contact Center.[2] 
  • The TPE review process includes up to three rounds of prepayment or post-payment probe review with education. 
  • If high denial rates continue after three rounds or review, your MAC will refer the provider and results to CMS. CMS will determine any additional action, which may include but is not limited to extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor (RAC).


Video on TPE by CMS [1]

HBOT Documentation Guidance 

To help minimize errors and be audit-ready, refer to this free checklist for documentation to support medical necessity in HBOT

In Summary: 

  • According to CMS [4], the nationwide program “will select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate.”
  • “MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” the agency said. “These providers/suppliers and specific items/services are identified by the MAC through data analysis.”
  • In a process similar to that adopted recently for the short inpatient admission review process by the Quality Improvement Organizations (QIOs), the audit process “includes a review of 20-40 claims followed by one-on-one, provider-specific education to address any errors within the provider’s reviewed claims.”
  • “Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education,” CMS continued. “In addition to education at the conclusion of each 20-40 claim probe review, MACs also educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.”
  • The new TPE will allow three rounds of audits before referral back to CMS to consider further action, such as referral to the Recovery Audit Contractors (RACs) or pre-pay review. 

Resources

The WoundReference Hyperbaric Oxygen Therapy Knowledge Base features guidelines to promote high standards of patient care and operational safety within the hyperbaric program and other important tools. The WoundReference Curbside Consult gives you actionable, specific answers from our expert panel in a timely manner. 

For customized safety programs and other wound care and hyperbaric medicine consultation services, visit MidWest Hyperbaric. 

Acknowledgement

We thank Julie Rhee ScM, for style editing

References:

  1. CMS.gov Target Probe and Educate - When Medicare Claims are submitted accurately, everyone benefits. 
  2. WPS GHA (MAC) 
  3. CMS Internet-Only Manuals (IOMs) Publication 100-03, Chapter 1, Part 1, Section 20.29, Hyperbaric Oxygen Therapy 
  4. Breaking: CMS Adopts Targeted Probe and Educate Policy Nationwide, RAC Monitor: Ronald Hirsch, MD, FACP, CHCQM


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