The Centers for Medicare & Medicaid Services (CMS) indicated in an August 2021 MLNConnects newsletter that the targeted probe and educate (TPE) program would resume ending the temporary suspension since in place since March 2020 due to the COVID-19 public health emergency (PHE). While an exact date for resumption was not provided, some Medicare Administrative Contractors (MACs), including Palmetto, WPS, Novitas, and First Coast, have already indicated either active topics, or confirmation of beginning TPE activity effective September 1, 2021.
The TPE is a national streamlined medical review process that was implemented by the MACs on Oct. 1, 2017. These MAC reviews only targeted providers based on data analysis identifying them as high risk for overpayments, or with unusual billing practices compared to peers, and/ or with high rates of denial. Section 3.2.5 of the Medicare Program Integrity Manual provides an overview for providers, noting the purpose of TPE as: to decrease provider burden, reduce appeals, and improve the medical review/education process.
What to Expect in a TPE
- TPE reviews can involve prepayment or postpayment claims.
- Providers receive a notification letter from their MAC informing them of TPE selection. The letter should outline the topic being reviewed, reasons for selection, process of review, and provide a direct point of contact. The MAC, First Coast Service Options, includes a letter sample on their website here.
- A single round of TPE typically involves the review of 20 – 40 claims. In rare circumstances, CMS may approve a probe sample of a claim count other than 20 – 40 claims.
- In addition to the provider notification letter described above, an Additional Document Request (ADR) will be generated for each claim selected.
Responding to TPE ADRs
- The process for responding to the claims review can become quite labor intensive. Providers have 45 days from the date of the ADR to submit documentation. However, MACs do have the discretion to grant an extension to providers who need more time to comply due to hardship. Providers should keep in close contact with their assigned TPE point of contact in the event hardship should arise. The MAC may refer providers to the Recovery Audit (RA) Contractor or the Unified Program Integrity Contractor (UPIC) if the providers fails to respond to the TPE.
- MACs will typically offer various methods for submitting documentation, which may include the provider portal, Electronic Submission of Medical Documentation (esMD), Fax, or USPS Mail. If submitting via USPS, providers should pay close attention to the specific instructions in the ADR. Documents must be one-sided, and generally, when submitting multiple claim responses in a single mailing, should be bundled as distinct claims with a copy of the corresponding ADR associated with that claim in order to facilitate proper handling and confirmation of receipt of the ADR response.
- MACs have 30 days from the date the documentation is received to review the documentation and make a payment determination.
Tracking TPE Review Outcomes
- At the conclusion of each probe round for the claims selected for review, a results letter with the review results for that probe will be sent. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part and associated education.
- Depending on denial error rates, providers may be required to participate in up to three rounds of TPE review, but the MAC may also continue through additional rounds at CMS’ direction.
- After each round, providers with moderate to high error rates are offered individualized education (usually held via teleconference or webinar) based on the results of their reviews. This is a great time for providers to interact with the MAC and ask claim specific questions. Providers are also offered individualized education during a round when errors that can be easily resolved are identified. The goal is for providers to learn from education and decrease future errors.
- Providers should understand that the error rate threshold indicating the need for a subsequent round of review will vary by MAC.
- If subsequent rounds are required, the MACs may begin requesting documentation as early as 45 days after the individual provider education is completed.
- Once a provider has achieved an acceptable error rate, they will be removed from review of that service and the MAC will continue to monitor their claims data on a proactive, routine basis.
- Provider claims that are denied in full or in part may be appealed through the normal Medicare Appeals process.
- Providers who continue with high errors after three rounds of TPE are referred to CMS for further action. CMS will determine any additional action required, which may include, but is not limited to a 4th round of TPE, extrapolation of error applied with subsequent recoupment of overpayments, referral to UPIC and/or the RAC.
According to CMS TPE Q&A document (Q14-15), there were 13,500 providers reviewed in FY2019, totaling 435,000 claims reviewed. Approximately 60% of these claims were accepted as billed, and less than 2% of providers and suppliers have failed all three rounds of TPE.
Contact Proactive to learn more about Medical Review support services including ADR preparation and Appeals management
Resources and Related Content
- Check out Proactive’s tips for effective ADR response here
- CMS TPE webpage
- CMS TPE Q&As
- CMS TPE Information Sheet
- CMS TPE video
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” Section 3.1‒3.7.5
- NGS: Significant Findings for TPE Review of Skilled Nursing Facility
- First Coast: TPE sample letter