On August 14, 2017, CMS announced an expansion of a Targeted Probe and Educate (TPE) review strategy for Medicare Administrative Contractors (MAC) reviews. Many providers were familiar with Probe and Educate reviews in connection with MAC audits of short inpatient claims under the Two Midnight Rule. Subsequently, CMS employed a pilot TPE program in one MAC jurisdiction in 2016 for multiple claim types, not just patient status. CMS’s most recent announcement expands the TPE program to all MAC jurisdictions.
According to CMS, the Probe and Educate approach involves a review of a sample of claims coupled with education to help reduce errors. Further, CMS states that the results of this approach have been favorable based on the decrease in the number of claim errors after providers received education.
When performing TPE reviews, MACs are instructed to select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. MACs are instructed to focus on specific providers/suppliers identified through data analysis who have the highest claim error rates or billing practices that vary significantly from their peers.
TPE involves the review of 20-40 claims per provider/supplier, per item or service, per round, for a total of up to three rounds of review. CMS states that providers will have some time between each round to facilitate improvement. Further, after each round, providers will be offered individualized education by the MAC based on the results of their reviews.
Providers/suppliers with moderate and high error rates in the first round of reviews will continue on to a second round of reviews with additional education. Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education. Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor (RAC), or other action.
Finally, providers/suppliers may be removed from the TPE review process after any of the probe review rounds, if they demonstrate low error rates or sufficient improvement, as determined by CMS.
Additional information is available here.
