CMS To Expand Targeted Probe and Education Program

Citing a decrease in appealed claim decisions and an increase in the acceptance of provider education under the pilot program, CMS has announced that they have decided to expand the Targeted Probe and Educate (TPE) program to all MAC jurisdictions in latter part of 2017. The TPE program grew out of the broad Probe and Educate program initiated by CMS in 2014. The TPE program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017.CMS has indicated that, when performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) will focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. The TPE review and education process includes a review of 20-40 claims followed by one-on-one, provider-specific, education to address any errors with in the provider’s reviewed claims. Providers/suppliers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 reviews, followed by additional, provider specific, one-on-one education. Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education. In addition to education at the conclusion of each 20-40 claim probe review.  MACs will also educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.

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, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.