CMS to Expand Audits, Education Targeted to Outliers

The Centers for Medicare & Medicaid Services (CMS) announced it will expand nationwide a pilot program in which Medicare administrative contractors (MACs) — like Novitas Solutions in Texas — review claims to prevent improper payments. 

The Targeted Probe and Educate (TPE) program builds on an earlier program whereby MACs reviewed claims to identify types with a high error rate and educated physicians on how to reduce these errors. TPE goes a step further by targeting for review and education specific physicians who have the highest claim error rates or whose billing practices vary significantly from their peers.

TPE involves reviewing 20-40 claims per physician, per service, per round, for a total of up to three rounds of review. After each round, or “probe,” the MAC will offer the physician individualized education based on the results of his or her review. The higher the physicians’ error rate, the more likely he or she will undergo a second or third probe. CMS says the term “probe” is “intended to convey that the number of claims reviewed is relatively small in comparison with previous provider specific review where the number of claims reviewed for an individual provider may have been much larger.”

Physicians with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100-percent prepayment review, extrapolation (using a statistical sample of the physician’s claims to determine overpayments), referral to a Recovery Audit Program contractor, or other action.

TPE is just one kind of claims audit MACs perform. See CMS’ reference guide for an overview of all CMS claim review programs. 

If you have questions about billing and coding or Medicare payment policies, contact the TMA’s reimbursement specialists at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955.

For more in-depth help, turn to the certified professional coders and auditors at TMA Practice Consulting to ensure your coding and medical record documentation follow Medicare billing guidelines. To learn more about an in-depth review, a check-up, or on-site training, call (800) 523-8776 or email practice.consulting[at]texmed[dot]org.

Published Sept. 12, 2017  

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Last Updated On

September 13, 2017

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