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Targeted Probe and Educate

Effective 10/1/2017, the CMS is expanding the existing Targeted Probe and Educate (TPE) pilot to include all MACs. TPE will include targeted medical review and education along with an option for potential elevated action, up to and including referral to other Medicare contractors including the ZPIC, UPIC, RAC, etc.

The goal of TPE is to reduce/prevent improper payments.

The purpose of this expansion is to reduce appeals, decrease provider burden, and improve the medical review and education process.

Key Elements of TPE

  • All current MAC medical record reviews are replaced with three rounds of pre-payment or post-payment TPE. If the provider’s error rate remains high upon completion of the first round, then the provider is retained for the second and, potentially, a third round of review.
    • Automated reviews and prior authorization directed by CMS are outside of the TPE strategy.
    • Note that any reviews or pilots otherwise mandated by CMS are excluded from this change.
  • Providers with a continued high error rate after three rounds of TPE will be referred to CMS for additional action
  • Your MAC will select the topics for review based upon existing data analysis procedures.
  • The claim sample size for each round of probe review is limited to a minimum of 20 and a maximum of 40 claims
    • Note that the sample is per provider, per topic, and per round.
  • The TPE process includes provider specific education that will focus on improving specific issues without allowing other problems to develop along with an opportunity for the provider to ask questions. Education will be offered after each round of 20 to 40 claims reviewed.
    • In addition, there is an opportunity for intra-round education as well if the nurse reviewer identifies a common theme that can be easily corrected during the review phase.

Provider Tips

  • Providers targeted for TPE will receive a notification letter (enclosed in a pink envelope) about the upcoming review and ADRs will be used for the specific claims selected for review.
  • Providers should ensure that medical records are submitted promptly upon request.
    • Reminder: ADRs must be responded to prior to the 45 day deadline (based on the date of the ADR) for each claim selected.
    • Providers are highly encouraged to respond to the ADR by sending all applicable medical records prior to day 45
  • Provider nonresponse to medical records requests will count as an error.
  • MACs may conduct a “related claim review” of services related to a denied claim and such reviews may be conducted outside of the TPE process.
  • The TPE process does not replace or change appeal rights.
    • The educational sessions are not an appeals forum nor do the result letters and/or the educational sessions extend the appeal period.

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