Following a temporary suspension in pre-payment reviews under the Targeted Probe and Educate (TPE) audit program in response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) announced in August 2021 that it would be resuming TPE reviews. Review under the TPE program is intended to be different than other audit reviews because the main goal is intended to be claim accuracy improvement through the use of several rounds of one-on-one education. However, a TPE audit can also have severe consequences for the provider. 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.
The TPE process is generally initiated when a provider receives an initial Notice of Review letter from their Medicare Administrative Contractor (MAC) which notifies the provider that they have been selected for a TPE review. This initial letter typically 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 involving 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, up to and including revocation of Medicare billing privileges.
After the Notice of Review, the MAC will send Additional Documentation Requests (ADR) for 20-40 claims. These ADRs may be indistinguishable from any other document requests, likely with no indication that they are pursuant to a TPE audit. The ADRs must be responded to within 45 days. After the provider submits the documentation, the MAC is required to provide direct one-one-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 claims review and education. If a high number of claims are again denied, the MAC will proceed to a third round.
A TPE review can take months or years to resolve and can have devastating impacts on a provider’s business, up to an including revocation of Medicare billing privileges and placement on the CMS Preclusion List. Closely monitoring the process of the TPE review is often critical to a successful resolution. First, a provider should keep its mailing address in PECOS current, as many communications regarding the review will be mailed to this address. 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 to a further round of review. Further, CMS may consider high levels of denials after three rounds, including denials on the merits and denials for failure to submit documentation, as a “patter or practice” of non-compliant billing that is grounds for revocation of billing privileges. Therefore, a provider should remember that claims denied under TPE can 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. If you or your healthcare entity has any questions pertaining to a TPE review or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or email@example.com.