Approaching the New Targeted Probe and Educate Program

The Centers for Medicare and Medicaid Services (“CMS”) expanded its Targeted Probe and Educate (“TPE”) program on October 1, 2017. The goal of the TPE program is to help providers be more cognizant of their billing practices so that they may provide improved services in the future.

TPE review is a process where providers who have high denial rates or unusual billing practices compared to other providers in their field are reviewed. Simple claim errors are typically why providers have high denial rates. Some examples of these errors include: missing a physician signature, encounter notes not fully supporting eligibility, documentation not meeting medical necessity, or missing/incomplete certifications or recertification.

When a provider is chosen for the program, they receive a letter from their Medicare Administrative Contractor (MAC). The TPE process involves an initial review, or “probe,” of 20-40 claims. If it is determined that the provider is non-compliant, a targeted, one-on-one education session will be offered to address errors found in the claims reviewed. Conversely, providers who are found to be compliant will not be reviewed again for at least one year. After the education session, providers have 45 days to make changes and improve. Those providers who continue to have high error rates after the first round must then proceed with a second round of reviewed claims and education. If high error rates continue, a third round will commence. After three rounds of TPE, if the provider continues to be non-compliant, they will be referred to CMS for further action. A provider can be removed from the review process at any point if they sufficiently demonstrate a significant reduction in their error rates.

TPE not only side-steps the harsh realities of a full-blown audit, but it gives providers an opportunity to educate themselves on why they may have been overbilling and how to correct the, usually minor, issue. Unfortunately, with the program being so new, the criteria for review has been applied inconsistently by the various reviewers leading to wrongful denials. As such, providers should keep in mind that it is possible to appeal an inappropriate TPE denial. This will bring the TPE denial into the standard Medicare audit appeals process—the most optimal result would be to have the denial overturned at the Redetermination phase.

At Wachler & Associates, we have found that before bringing an improper TPE denial through the appeals process, a provider should contact CMS about their concerns of the reviewer using improper criteria to wrongfully deny claims. Furthermore, demonstrating an attempt to become compliant after an initial review, even if the reviewer does not deem the provider substantially compliant, can show commitment to Medicare’s standards which may assist in the provider being taken off TPE review. Some ways to accomplish this would be to hire a compliance attorney, draft a compliance plan, and implement the requested changes after the first stage of review.

For over 30 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 if they are chosen for a TPE review. Wachler & Associates will continue to stay up to date with TPE reviews and other alternative dispute resolution processes for reviewing claims.  If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.