They’re ba-ack! Targeted Probe and Educate (TPE) audits. The Centers for Medicare and Medicaid Services (CMS) resumed the TPE audits in August, just a short time ago. Why? Because they have a goal to help us quickly improve the accuracy of our claims. The Medicare Administrative Contractors (MACs) work with providers to identify errors and help correct them since many common errors are simple oversights, such as a missing physician’s signature, and therefore are easily corrected. The overall goal of a TPE is to increase the accuracy in our documentation practices in very specific areas (target areas).

MACs will use claims data elements to select the medical charts to review.  Specifically, the data elements MACs use are:

  • High claim error rates or unusual billing practices, and
  • Items and services that have high national error rates and are a financial risk to Medicare.

If a provider whose claims are in compliance with Medicare policy, they won’t be selected for a TPE.

Common errors identified in TPEs are:

  • Physician signature is missing
  • Encounter notes do not support elements of eligibility
  • Documentation does not reflect medical necessity
  • Missing or incomplete initial certifications and recertification

What does a TPE look like?

  1. The first step is an Additional Development Request (ADR) from the MAC. This is a notification letter sent to you, the provider, informing you that you have been selected for a TPE because certain data elements have placed you in an outlier status. In this letter, the MAC will provide a list of 20-40 claims requesting supporting documentation to be provided within forty-five (45) days.
  2. Once the MAC reviewer completes the documentation review, it is then determined whether you are in compliance or not compliant.
    1. If you are compliant, you will not be reviewed again for at least one (1) year on the selected topic. 
    1. If the MAC reviewer determines that you are not in compliance, the claims will be denied, and you will be invited to a one-on-one education session with the MAC reviewer. At that point, you then go to round two where the entire process begins again.
    1. If after three (3) rounds of medical record review and education sessions, you fail to improve, the MAC will refer you to CMS for next steps. These next steps may include 100% prepayment review, extrapolation, referral to a Recovery Auditor, or other government auditing entity.

How can you avoid a TPE?

Well, it’s not a matter of IF you are going to receive an audit, it’s a matter of WHEN. TPEs are no exception. The best course of action is to identify whether or not you are an outlier and if you are, does your documentation support your billed claims? Even if you are not an outlier, you should know what your documentation looks like, where your vulnerabilities are, and ensure an ongoing auditing and monitoring plan is in place. If you need help, reach out to learn more about our consulting services at consulting@fprehab.com. If you are a Functional Pathways’ client partner, reach out to me directly, we can help!

Gina Elkins, CHC, OHCC, RAC-CT, LPTA | Senior Director of Compliance & Regulatory Strategy