CMS Targeted Probe & Educate (TPE) White paper

CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.

The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple – such as a missing physician’s signature – and are easily corrected.

Downloaded from Source: CMS.gov

Targeted Q&A Whitepaper

Targeted Probe and Educate (TPE) Q & A’s

• Q1. What is Targeted Probe and Educate? A1. When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers that bill a particular item or service rather than all providers/suppliers billing a particular item or service. MACs will focus only on providers/suppliers who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers. TPE typically involves the review of 20-40 claims per provider/supplier, per item or service. This is considered a round, and the provider/supplier has a total of up to three rounds of review. After each round, providers/suppliers are offered individualized education based on the results of their reviews. Providers/suppliers are also offered individualized education during a round when errors that can be easily resolved are identified.

• Q2. Why did CMS move to the TPE process for medical review? A2. The results of previous Probe and Educate (P&E) programs have been well received by the provider/supplier community. Additionally, positive results of the TPE pilot program included a decrease in appeals as well as an increase in provider education which resulted in decreased denial rates for a vast majority of providers as they progressed through the P&E process. These initial P&E programs, however, included all providers/supplier that billed a particular service. In an effort to refine the P&E programs, CMS determined that efforts would be better directed toward those providers/suppliers who, based on data analysis, provide the most risk to the Medicare program, and not to all providers/suppliers billing a particularitem/service.

• Q3. How will a provider/supplier know if they have been selected for TPE review? A3. Providers/suppliers who are included in the TPE process will receive a notification letter from their MAC. This letter will outline why the provider/supplier has been selected for review as well as what to expect throughout the review and education process.

• Q4. Why are the TPE probe sample sizes generally set at 20-40 claims? A4. The 20-40 claim sample size is intended to allow the MACs to review enough claims to be representative of provider/supplier behavior. This allows MACs and to assess whether claims generally have the necessary supporting documentation to meet Medicare rules and requirements, while not being overly burdensome.
• Q5. What happens if there are errors in the claims reviewed? A5. At the conclusion of each round of 20-40 reviews, providers/suppliers will be sent a letter detailing the results of the reviews and offering a 1-on-1 education session. MACs will also educate providers/suppliers throughout the TPE review process, when errors that can be easily resolved are identified, helping the provider to avoid additional similar errors later in the process. CMS’ experience has shown this educational approach is well received by providers/suppliers and helps to prevent future errors.
• Q6. What should a provider/supplier expect during a 1-on-1 education session? A6. During a one 1-on-1 education session (usually held via teleconference or webinar), the MAC will educate the provider regarding claims with errors representative of those identified during review. Providers/suppliers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed.
• Q7. What error percentage is considered a “high denial rate” and what other factors are used to determine whether a provider moves on for additional review? A7. The error percentage that qualifies a provider/supplier as having a high denial rate varies, based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. Other factors that determine the need for additional review may include but are not limited to decrease in error rate with each round, as well as participation in and improvement with education.
• Q8. Can claims reviewed as part of the TPE process be appealed? If a claim is appealed and overturned, would this impact the provider denial rate? A8. The appeals process is unchanged under the TPE process. If a claim denial is appealed and overturned, this would be taken into consideration in subsequent TPE rounds. If the appeals results are not available at the time a provider progresses to a second or third round of TPE, but are available when the provider is referred to CMS, CMS takes these results into consideration when determining the need for additional action. If a provider’s adjusted error rate, after appeals, indicates no need for additional review, CMS will make that recommendation, and the provider will be monitored by the MAC as they would be had they passed the TPE process and been released from review.
• Q9. Under the TPE program, do the MACs send a letter to the provider/supplier with details regarding the results of their reviewed claims? A9. At the conclusion of each round of review, the MAC sends the provider/supplier a letter detailing the results of the 20-40 claims reviewed during that round, including details regarding claim errors. This letter may be sent before or after the final one-on-one educational call.
• Q10. Is the education provided after each round provider/supplier-specific or general education given to all providers/suppliers? A10. The education session after each round is developed based on the review findings from the most recently completed round of reviews and is not the same as that given to other providers/suppliers unless errors found in the reviewed claims are the same. The education will reinforce corrections that should be made for errors that continue to be identified.
• Q11. Will previous Probe and Educate (P&E) review results be used to identify providers who will be included in TPE? A11: CMS is encouraging MACs to use all available sources of data when selecting providers to include in the TPE process. The results of previous P&E programs is one source of data MACs will use to select providers for review. MACs will also use provider billing and utilization patterns, as well as provider specific error rates.
• Q12: Can a provider/supplier be included in multiple TPE probes at the same time? A12: Yes, if a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review. Additionally, if a provider/supplier submits claims to Medicare for more than one item or service, each item/service could be subject to a separate probe as part of the TPE program. Providers/Suppliers and the specific items and services included in the TPE process are those who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers.
• Q13. When a provider/supplier is moved to an additional round of TPE review, when should the provider expect the additional reviews to start? A13. MACs can begin sending documentation requests for claims with dates of service no earlier than 45 days after the previous post-probe one-on-one education. This time gives the provider/supplier the opportunity to make changes based on the education received prior to being subjected to additional review. If a provider declines to schedule education within a reasonable time after receiving the offer, subsequent reviews will be for claims with dates of service no earlier than 45 days from the one-on-one post probe education offer.
• Q14. How many provider/suppliers were reviewed on TPE in Fiscal Year 2019? A14. From October 2018 to September 2019 approximately 13,500 providers and suppliers were started on TPE. Of those started, less than 2%* of providers and suppliers have failed all three rounds of TPE. * Note, this percentage is based on all providers/suppliers who started round 1 of TPE and those who have completed all three rounds. Providers and Suppliers still on review, are not yet counted.
• Q15. How many claims were reviewed and accepted as billed in the TPE program in Fiscal Year 2019? A15. Approximately 435,000 claims were reviewed from October 2018 to September 2019 and approximately 60% were accepted as billed.
• Q16. How many educational contacts were completed in Fiscal Year 2019? A16. There were approximately 90,000 intra- and post-probe educational contacts. Educational contacts include, but not limited to: phone calls, face-to-face visits, webinar/e-visits, emails, and letters.