Monday, August 28, 2017

CMS Announces Nationwide Expansion of Targeted Probe and Educate Medical Review Strategy

On August 14, the Centers for Medicare and Medicaid Services (CMS) announced a significant change in direction in their medical review strategy. CMS states they are cognizant of issues of provider burden associated with the traditional medical review process, and have been seeking ways to better target providers that require further education in order to reduce payment errors. What began as a small-scale targeted probe and educate (TPE) pilot with one Medicare administrative contractor (MAC), which was well-received by providers and reduced claim error rates and appeals, is to be expanded nationwide in late 2017.
How Targeted Probe and Education (TPE) works
When performing medical review as part of TPE, MACs focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE involves the review of 20 to 40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20 to 40 claim reviews is referred to as a probe. 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.
MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers.

Opportunity for Providers to Implement Corrective Processes 
The TPE review and education process includes a review of 20 to 40 claims followed by one-on-one, provider-specific education to address any errors within 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 to 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 (please see the TPE Process Flowchart). In addition to education at the conclusion of each 20 to 40 claim probe review, 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.

Providers/suppliers with 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. Providers/suppliers 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. 

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