Targeted Probe and Education (TPE)

Ready or not Targeted Probe and Education (TPE) is happening.

Since 2014, CMS directed and MAC administered Probe and Educate Strategies have been in existence. In 2017 CMS introduced changes to this program to allow the MACs freedom to decide both the topic and the provider to be targeted. The intent of this expansion is to reduce appeals, decrease provider burden and improve the medical review/education process.

Through data analysis the MACs will identify the top 5-10 “problem areas” most burdensome to CMS in their region. Further data analysis will then be performed by the MACs to identify those providers with a high number of denied claims, unusual billing practices or who are outliers in comparison to their peers. These providers will then be selected for review by the MAC of up to 3 rounds of 20-40 charts for the identified topic. Based on the review findings, one on one education sessions will be provided to allow for correction of errors on future claims. Forty-five to fifty-six days after the education session occurs a second round of auditing will take place. The MAC may conduct up to three rounds of audits. If there has not been a correction in the identified errors after 3 rounds of audits, then the MAC will escalate the issue to CMS. Escalation to CMS opens the potential for additional actions such as 100% pre-payment reviews, RAC audits and extrapolations to name a few.

The data analysis method by which “problem areas” are identified and by which providers are deemed to have high denial rates or outlier status are at the sole discretion of the MACs. Not having insight into the MAC data analysis methods puts providers at a disadvantage in terms of taking action to ensure they are falling within the mean to avoid being identified for a TPE audit.

Never has the old saying “The best defense is a good offense” been truer. Addressing vulnerabilities in documentation, coding and claims before submission is key to avoid being identified for a TPE audit. An approach guided by data analysis will allow an organization to effectively identify those areas of vulnerability and take proactive corrective measures.

To keep up date on other pertinent industry issues be sure to check back here next month.