Are You in Line for a Medicare Targeted Probe and Education Audit?
It’s known as a TPE review. Have you heard of it? A Centers for Medicare & Medicaid Services (CMS) Targeted Probe and Education audit is a periodic review with the goal of reducing claim denials and appeals by providing claim review along with one-on-one provider education.
This is no trivial review. If the provider does not show compliance at the end of the review process, the consequences may be serious and may even include revocation of Medicare billing privileges.
What Is Involved in a TPE Review?
A Medicare Administrative Contractor (MAC) conducts the TPE review and has wide discretion on its process.
Healthcare providers and suppliers are selected for the audit based on data analysis, targeting those providers and suppliers with high denial rates or with claims activity that appears unusual when compared to peers. The review usually focuses on a claim prepayment basis, although post-payment audits are also considered. Generally, 20-40 claims are sampled.
Some of the claim errors that may trigger a TPE audit include:
Missing physician signature
No medical necessity documentation
Encounter notes missing eligibility elements
If, based on the TPE review, the provider or supplier is regarded as compliant, they will not be reviewed on that particular basis for at least one year. However, when the MAC finds noncompliance, another round of review is required preceded by one-on-one education sessions.
Education Is a Major Goal of TPE Audits
CMS requires that education is a major focus of both the claims review process and post-review. The one-on-one education sessions may be face to face or via the telephone or webinar.
After the one-on-one counseling, the provider or supplier has at least 45 days to correct any errors before the next round of claims review. After three rounds of education, the provider will be referred to CMS for further action.
Potential negative outcomes of a TPE audit include revocation of billing privileges if there is a pattern of submitting sub-standard claims; removal from participating in Medicare; fraud investigation.
Providers and suppliers must comply with Medicare requirements in submitting documentation on a timely basis and keeping supporting records to demonstrate compliance.
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