This post has been modified or updated.
Learn more about our services here or shop our tools and resources here.

CMS has announced plans to expand the targeted probe approach to medical review to all MACs (Medicare Administrative Contractors.) TPE includes processes for communication and education with providers that has been shown to help reduce errors. TPE will select review topics based on data analytics, and focus ADR activity on providers with the highest claim error rates or outlier billing practices.

CLAIM SELECTIONS: TPE involves probe review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. After each round, providers are offered individualized education based on their review results.

PROBE & REVIEW PROCESS: Providers with moderate or high error rates will move on to additional rounds of 20-40 reviews which will again be followed by one-on-one education. Providers who have high error rates after round two will continue on to a third (and final) round of probe reviews and education. Providers who have shown continued high error rates after three rounds of TPE may be then referred to CMS for additional action such as 100% prepay review, extrapolation, or referral to other review contractors e.g. RAC or UPIC. If low error rates or sufficient improvements are observed, a provider may be removed from the review process following any of the three rounds of probe review.

Medical Review Preparedness & Response:
Robust Medicare Compliance Programs, strong auditing and monitoring systems and an effective medical review response plan will help you to prepare for TPE. Proactive’s proven systems help to reduce risk and increase favorable audit outcomes. Contact us today for information on training, auditing, and medical review assistance services.

Proactive Client ADR Success Rate = 90%
Non-Client Peers with <40%