Q What are Targeted Probe and Educate reviews?

A These are another form of Medicare claims data-driven reviews done by your Medicare Administrative Contractor. A pilot, less targeted, program began in 2014 involving one MAC. In June 2016 it became more targeted, and in July 2017, it expanded to three more MACs; it will expand to all MACs by the end of 2017. CMS notes that the pilot “… combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy “Probe and Educate.” CMS believes the results of this program have been favorable, based on the decrease in the number of claim errors after providers received education.”

Q Why are these being implemented now in addition to all the other types of reviews already present?

A As alluded to above, because of the decrease in error rates on claims and the documentation to support them, CMS felt the program was successful. On the TPE webpage,¹ they explained their rationale for moving to a more focused approach: “CMS is now further improving this strategy by moving from a broad Probe and Educate program to a more targeted one. When performing a medical review as part of Targeted Probe and Educate, MACs focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service.”

Q How many charts might this entail?

A CMS notes that this will involve 20 to 40 claims per provider, per item or service, or per round. There will be up to three rounds of review.

Q Why are there three rounds of TPE reviews?

A CMS refers to each of the rounds as a “probe.” They note that “This term 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. After each round, providers are offered individualized education based on the results of their reviews.” CMS says that if providers do well on early rounds, they are less likely to go through subsequent rounds. They state, “Whereas previously the first round of [other types of] reviews were of all providers for a specific service, the TPE claim selection is provider/supplier-specific from the onset. This eliminates burdens to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.”

Q How do the MACs choose what gets reviewed?

A CMS “will 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 will focus only on providers/suppliers who have the highest claim-error rates or billing practices that vary significantly out from their peers. These providers/suppliers and specific items/services are identified by the MAC through data analysis.”

Q How is the decision to perform subsequent reviews made?

A CMS notes, “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.” In other words, providers and suppliers who have moderate and high error rates after round one continue to a second round. Those with high error rates in round two move to round three. The definition of what constitutes “low,” “moderate” and “high” is determined by CMS.  

Medicare also notes that “MACs 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.”

Q What sort of education gets provided if I don’t do well after a round?

A CMS does this in a “one-on-one education session (usually held via teleconference or webinar), [where] the MAC provider outreach and education staff will walk through any errors in the provider/supplier’s 20 to 40 reviewed claims. 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.”  Generally, it would take six to eight weeks for changes to be implemented and claims filed and processed before the next round begins.

Q What happens if I don’t do well on round three of TPE?

A Medicare says those providers and suppliers can be referred for additional actions (which are more serious). They note “continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

For instance, 100 percent pre-payment review means that all services will require records submission, review by the MAC, and a determination of correctness before any payment is forthcoming. This could have a significant financial impact on those practices and providers in terms of cash-flow management.

Extrapolation means your error rate on the small number of claims is applied to all your submitted claims for a payer. Defending this could become extremely burdensome and expensive.

Q How do I protect myself from a TPE review?

A If you provide a high number of a particular service to Medicare beneficiaries compared to your peers, you might be selected for TPE “round one.” As CMS moves to more robust data analysis, they are focusing their reviews far more specifically. It’s likely that private payers will use your claims data in the same way, if they aren’t already. Your documentation and support for medical necessity in your charts for the services you deliver is likely to be the determining factor on how well you do. Careful attention to any and all payer policies and standard of care are a key factor.

Q What resources does CMS provide to help me?

A CMS has a “TPE Q&A” that was produced on October 25, 2017.  It is available on the TPE webpage in the “Downloads” area.  

Mr. Larson is a senior consultant at the Corcoran Consulting Group. Contact him at plarson@corcoranccg.com.

^{1. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html accessed 26 October 2017.}