Frequently Asked Questions Surrounding Medicare’s Targeted Probe and Educate Review Program

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If you are anything like this author, there are a few traits in particular that you always want to follow: 1) do your best work; 2) follow clinical guidelines, as well as coding, payment, and coverage guidelines; 3) receive appropriate payment for your work; and 4) prevent claim denials and/or repayments. Also, like this author, readers probably prefer to be told when a mistake has been made and to be appropriately educated as to how to prevent the same mistake from recurring. It also seems reasonable to assume that most of us do not like to undergo payer medical reviews on topics that we always diagnose, document, code, and charge correctly. Unfortunately, many past medical reviews conducted by Medicare Administrative Contractors (MACs) were performed on all claims submitted by providers and suppliers for the topic undergoing medical review. That created an unnecessary burden on providers and suppliers who were not violating any coding, payment, or coverage regulations. Therefore, most wound care providers and suppliers should be happy with Medicare’s new Targeted Probe and Educate (TPE) medical review program that was implemented nationwide by the Centers for Medicare & Medicare Services (CMS) Oct. 1, 2017. The TPE program reduces improper payments and denials as well as the burden of unnecessary medical reviews of compliant providers and suppliers. Because many readers of Today’s Wound Clinic have submitted questions about the TPE program, this edition of Business Briefs will provide answers to the most frequently asked questions regarding TPE. 

QUESTION 1 

Is it true that TPE began as a pilot program of the CMS?

Answer: Yes, CMS conducted a less targeted pilot program known as Probe and Educate that began in 2014 and involved one MAC before expanding to other providers in June 2016 and to three more MACs in July 2017. During the pilot programs, CMS selected the medical review topics, and all providers in those states were subject to the reviews. The pilot programs produced favorable outcomes (eg, reducing improper payments, decreasing denial rates, decreasing appeals, and educating providers and suppliers). Many providers and suppliers who participated in the pilot programs reported that the education they received was very helpful. They also reported that they liked having one MAC medical reviewer to communicate with (and work with) throughout the process.

QUESTION 2

What are the major differences between the pilot program and the newly implemented nationwide TPE program?

Answer: In addition to an improved process, there are two major differences:

1. Based on data analysis, the MACs will select the medical review items and services that have high national error rates and are a financial risk to Medicare.

2. Based on data analysis, the MACs will identify specific providers and suppliers who have high claim error rates or unusual billing practices (rather than reviewing 100% of the providers and suppliers who bill a particular item or service). In the opinion of the author, this is great news for well-performing wound care providers and suppliers who are compliant with Medicare policies: They will most likely not be chosen for the TPE program. This is also good news for underperforming providers and suppliers: The new TPE program will educate them on how to quickly improve their documentation and billing practices.

QUESTION 3

What is the purpose of CMS expanding the medical review pilot programs to all MACs, and what are the objectives of the TPE medical reviews?

Answer: The purpose of the TPE program expansion to all MACs is to reduce appeals, decrease provider burden, and improve the medical review/education process. The objectives of all medical reviews are to:

• identify and prevent inappropriate payment,

• identify potential risk to the Medicare trust fund,

• educate providers, and

• appropriately pay for covered services.

QUESTION 4

What are some common claim errors that cause a provider/supplier to be enrolled in the TPE program?

Answer: CMS has released four common claim errors: 1) the signature of the certifying physician is not included; 2) documentation does not prove medical necessity; 3) encounter notes do not support all elements of eligibility; and 4) missing or incomplete initial certification or recertification.

QUESTION 5

Is it true that the TPE program can include three rounds of medical reviews?

Answer: The MACs shall perform prepayment or post-payment provider-specific/supplier-specific reviews. The TPE process can include up to three rounds of medical reviews that CMS refers to as “probes.” CMS uses the term “probe” to convey that the number of claims reviewed is relatively small in comparison with previous provider-specific/supplier-specific reviews in which the number of claims reviewed for an individual provider or supplier may have been much larger. Once the MAC selects a topic to probe and identifies the providers to target (based upon data analysis) Round 1 of the TPE probe begins.  

Round 1 of TPE Probe

The MAC medical reviewer who is conducting the probe will contact the targeted provider or supplier to determine the contact person for the TPE medical review probe notice and to identify the point person for the medical reviewer throughout the TPE process. Next, the medical reviewer will mail the initial probe notification letter to the targeted provider or supplier. The notice will state the reason for the probe, the number of claims that will be requested (between 20 and 40), and the accuracy percentage benchmark that will be used to determine if a provider or supplier is compliant or noncompliant for that particular probe. Each MAC will set the accuracy percentage benchmark, which may vary for each of the different topics/codes. The initial notification letter will also include a checklist of the documentation that should be submitted for a successful TPE probe. 

NOTE: The provider or supplier should not send any documentation in response to the initial TPE probe notification letter. The provider or supplier will then receive “additional development requests” (ADRs) for each claim selected for review and should submit the documentation for each selected claim within 45 days of the request. Because the 45-day window includes mail time and the contractor’s processing time to a medical review location, some MACs highly recommended that providers and suppliers send their documentation within 30 days of ADR receipt. If documentation is not submitted for one or more of the specified claims, the claim(s) will be counted as “noncompliant.” 

NOTE: Those who do not respond could be referred to the Recovery Audit Contractor (RAC), the Zone Program Integrity Contractor (ZPIC), or the Unified Program Integrity Contractor (UPIC). For prepayment TPE probes, the medical reviewer assigned to that provider or supplier will review the submitted documentation within 30 days of receipt and will send a detailed results letter to the provider or supplier. For post-payment probes, the medical reviewer has 60 days to complete the review. The probe-results letter will outline the TPE process, provide reasons for claim denials (including pertinent Medicare regulations), delineate the provider’s or supplier’s payment error rate, release compliant providers or suppliers from further TPE rounds, and offer one-on-one education to noncompliant providers or suppliers and enter these folks into the next TPE probe round. For example, if the TPE probe found that the claims met the compliance percentage benchmark set for that probe, the TPE for that provider or supplier will be discontinued for that topic/code for at least 12 months. If the TPE probe found that the claims did not meet the compliance percentage benchmark set for that probe, one-on-one education will be offered to the provider or supplier who will enter Round 2 of the TPE program. 

In the author’s opinion, noncompliant providers and suppliers should always take full advantage of the education opportunities offered and should carefully review the information provided in the results letter. They should also make sure they understand their error(s) and what they need to do to correct the problem(s). Once the education has been completed and the results letter has been carefully reviewed, the provider or supplier should implement appropriate corrective action(s), such as improving documentation, selecting correct codes, and training key personnel who are able to assure that the provider’s or supplier’s documentation and claims meet Medicare guidelines.

Round 2 of TPE Probe

The MAC will allow more than 45 days to pass after the one-on-one education so that the providers and suppliers have time to improve. Next, approximately 45-56 days after completion of the education from Round 1, the MAC will issue ADRs for another 20-40 claims that will be reviewed in the Round 2 probe. The requested claims must be dated after the Round 1 educational intervention. The MAC medical reviewer will follow the same process as previously described for Round 1. If the medical reviewer still finds that the claims do not meet the compliance percentage benchmark set for that probe, another education session will be offered to the provider or supplier, who will enter Round 3 of the probe. 

Round 3 of TPE Probe

The Round 3 process is identical to the first two rounds. Providers and suppliers should do everything possible to pass Round 3, because failing it may lead to dire consequences. If the medical reviewer still finds that Round 3 claims do not meet the compliance percentage benchmark set for that probe, the MAC shall refer the provider or supplier to CMS for possible further action. That additional action might include extrapolation of overpayments across the provider’s or supplier’s entire claims history, referral to the ZPIC or UPIC, referral to the RAC, or 100% prepay review. 

See the Figure at right for a flow chart of the TPE process. 

QUESTION 6

The initial notification letter that informs a provider or supplier that he/she is entered into the TPE process appears very important. How can providers and suppliers be sure the correct person receives that notification letter? 

Answer: The initial notification letter will be mailed to the provider or supplier contact at the enrollment address that is listed on the MAC’s file. Providers and suppliers should double-check, as soon as possible, that their contact and mailing address on file with CMS is accurate by logging into the Provider Enrollment, Chain, and Ownership System. 

Prior to sending the initial TPE notification letter, the MAC medical reviewer will reach out to the contact on file to be sure he/she is the correct person to monitor the TPE process and to provide initial information. Be sure that the contact person listed is aware of the possible TPE probes and either accepts the responsibility to monitor the TPE process or provides a different contact to the medical reviewer.

QUESTION 7

What will the MAC medical reviewer look for?

Answer: The medical reviewer will review the medical records for technical components (eg, physician certifications, physician orders, and beneficiary election statements) and for eligibility (eg, Medicare coverage guidelines, medical necessity, and documentation that supports the services billed). 

QUESTION 8

Will the medical reviewer only contact the provider before and after the TPE probe?

Answer: The beauty of the TPE process is that the medical reviewer will communicate with the targeted provider or supplier throughout each round of the probe. In fact, the medical reviewer will make intra-probe calls if the reviewer identifies an issue that is easily curable. 

The medical reviewer will simply contact the provider or supplier, ask for such things as missing orders, and bring attention to repetitive issues that can be fixed before additional claims are submitted. The medical reviewer will always contact the provider or supplier after the probe of all the claims is complete. 

At that time, he/she will offer to make an appointment for an individualized educational intervention based on the results of the probe. The provider or supplier should accept the offer and try to select a time for the education when team members who could benefit from the education will be available to participate. 

QUESTION 9

What should providers and suppliers expect to happen during the educational interventions?

Answer: The goal is for providers and suppliers to learn from the education and to improve their claim-review results in the next round of TPE probes. 

Because process improvement is a key part of the TPE program, the educational interventions will focus on improving specific issues identified during the probe and will provide education to prevent other problems from developing. The medical reviewer will also reinforce compliant parameters. Finally, the educational interventions will give the providers and suppliers the opportunity to ask specific questions regarding their claims and the CMS policies that apply to the item or service that was reviewed.   

QUESTION 10 

Will the targeted provider or supplier receive a written review after each round of the TPE process?

Answer: Yes, at the end of each TPE probe round, the medical reviewer will provide a written overview of the results. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part, the reason for denials, and the Medicare regulations pertaining to the results. 

QUESTION 11

Once a targeted provider or supplier is found to be compliant and is discontinued from TPE, will the MAC stop monitoring data analysis?

Answer: No, the MAC will continue to monitor, through data analysis, the providers or suppliers who had identified risk during their probe round(s) and who were discontinued from TPE. The MAC shall conduct a follow-up review in approximately one year, when data analysis indicates that possible risk behaviors may be suspected. 

QUESTION 12

In past years, providers and suppliers often ignored ADRs. If they continue that practice and ignore the TPE program’s ADRs, will they incur consequences greater than claim denial?

Answer: In the past, some MACs may not have been including ignored ADRs in their provider error rates. However, CMS has directed MACs to include claims denied due to no response to ADRs when calculating the provider error rate. That provider error rate is important because it is a determining factor as to whether the provider or supplier gets targeted for a TPE probe. Some of the other determining factors are the total dollar value of the problem and history of the provider or supplier. In this author’s opinion, all targeted providers and suppliers should do their best to submit the required documentation for every ADR. Some documentation is better than no documentation, which automatically is counted as a denied claim. 

QUESTION 13

Are there any online resources that providers can access to learn more about the TPE program?

Answer: Yes, a plethora of TPE program resources are available:

• Change Request 10249 provides direction to the MACs to conduct all medical record reviews by following the TPE process.¹
• The MACs’ websites include detailed information pertaining to the TPE process, notice of medical review topics, ADR resources, medical documentation checklists, signature requirements, etc. Visit the following entities online: CGS,^® First Coast Service Options Inc.,^® National Government Services,^™ Noridian Healthcare Solutions, Novitas Solutions, Palmetto GBA,^® and WPS^TM Government Health Administrators.
• The MACs have conducted webinars pertaining to the TPE process; many of the webinars and slides are archived on their respective websites.
• CMS offers a TPE webpage that is very educational and thorough.²

QUESTION 14

Can the TPE program have any unintended consequences for some wound care professionals?

Answer: Providers and suppliers with outlier tendencies and who have claims error and billing rates significantly outside the norms are the primary targets of the TPE program. In this author’s opinion, physicians or other qualified healthcare professionals (QHPs) who provide a high number of wound care procedures (in comparison to their specialty-society peers who do not provide wound care) may be more susceptible to TPE probes. However, if these physicians or QHPs read and follow the local and national coverage determinations, thoroughly document their work, write specific orders, sign all of their documentation and orders, code correctly, and charge appropriately, they should be able to meet and/or exceed the percentage benchmark in Round 1 and should be dismissed from the TPE process. Remember, the process targets the wrongdoer, not providers and suppliers who regularly submit correct claims. 

SUMMARY 

The newly implemented nationwide TPE program should reduce appeals, decrease provider burden, and improve the medical review and education process. Compliant providers and suppliers should not be burdened by probes that are not pertinent to them. Noncompliant providers and suppliers will find the TPE process less burdensome because the number of claims that can be reviewed in each round is limited to between 20 and 40. The targeted providers and suppliers should do everything possible to submit the requested documentation on time. The medical reviewers are mandated by CMS to complete their reviews of the submitted documentation for prepayment probes within 30 days of receipt and for post-payment probes within 60 days of receipt. Then, the medical reviewers provide education to the noncompliant providers and suppliers. Those who are compliant will be discontinued from the program; only the noncompliant will proceed through additional rounds of probes. For providers and suppliers who want to comply but may not have been adequately educated, the TPE process is a kinder and gentler way to undergo an audit and, most importantly, to learn from the TPE education, in this author’s opinion. At that point these providers and suppliers should be well equipped and highly motivated to implement the appropriate corrective actions and join the ranks of compliant folks.  

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net

References

1. CMS Manual System. Pub 100-20 One-Time Notification. Transmittal 1919. U.S. Department of Health & Human Services. 2017. Accessed online: www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r1919otn.pdf

2. Targeted Probe and Educate (TPE). CMS. 2018. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educate.html