A healthcare practice or other provider or supplier receives a letter from their Medicare Administrative Contractor (MAC). The letter notifies the provider that they have been selected for a Targeted Probe and Educate (TPE) review. This initial letter, the Notice of Review, likely does not include any specific records requests but indicates that the MAC will request records at a later date. The letter may briefly describe the TPE process as including three rounds of claims review with education after each round. This letter will likely warn that, if a provider/supplier fails to improve the accuracy of its claims after three rounds, the MAC will refer the provider/supplier to CMS for additional action, such as prepayment review, extrapolation of overpayments, referral to a RAC, or other disciplinary action.
A provider or supplier navigating a TPE review should take care to comply with the program’s requirements and timelines and should be aware of the potential consequences of a review. A TPE review can take months or years to resolve and can have devastating impacts on a provider’s business, up to and including revocation of Medicare billing privileges and placement on the CMS Preclusion List.
After the Notice of Review, the MAC will send Additional Documentation Requests (ADR) for 20-40 claims. However, these ADRs may be indistinguishable from any other, with no indication of the added importance of being pursuant to a TPE audit. The ADRs will require a response within 45 days. After the provider submits the documentation, the MAC is required to provide direct one-on-one education to the provider. The MAC will then issue a letter that outlines its findings. If a high number of claims are denied, the MAC will proceed to a second round of review of 20-40 claims and education. If a high number of claims are denied again, the MAC will proceed to a third round.
Closely monitoring the process of the TPE review can be critical to a successful resolution. First, a provider should keep its mailing address in PECOS current, as much of the communication regarding the review will be mailed to this address. Once a provider is under review, it may consider directly communicating with representatives of the MAC as well. Second, failure to respond to the ADRs will likely result in claim denials. Third, failure to schedule or participate in any education offered by the MAC may lead the MAC to proceed to another round of review. Further, CMS may construe high levels of denials after three rounds, including denials on the merits and denials for failure to submit documentation, as a “pattern or practice” of noncompliant billing that is grounds for revocation of billing privileges. Therefore, a provider should remember that claims denied under TPE can and should be appealed within the normal claims appeal timeframes. By the time a provider is appealing a revocation based on a TPE review, the deadlines to appeal the claims have often long passed and CMS may treat the denials as final.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in navigating or appealing a TPE review. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or firstname.lastname@example.org.