Targeted Probe and Educate (TPE): What Should I Expect?
Have you received a letter from your Medicare Administrative Contractor (MAC) that you have been selected for a TPE? It is always stressful to be under review, but a better understanding of the process may help decrease your anxiety and allow you to be better prepared in case you are ever selected.
In reviewing claims, The Centers for Medicare & Medicaid Services (CMS) looks for patterns of errors. In October of 2000, CMS initiated the Progressive Corrective Action (PCA) program with the aim of improving accuracy of Medicare payments by targeting incorrect billing patterns and educating providers and correcting issues. This PCA process was replaced in March of 2018 with the Targeted Probe and Educate (TPE) program. TPE is now the current recognized format of progressive corrective action.
The TPE strategy selects high error rate providers for up to three progressive rounds of medical review, with 20-40 claims and supporting medical records potentially reviewed each round. If compliant, you will not be reviewed again on the selected topic for at least one year. If errors are found in the first round, you will be invited to a one-on-one education session and then an interim period of at least 45 days is provided for implementation of improvements. After the interim period, providers with error rates above the targeted range (usually 10%) may be referred for a second round of medical review of 20-40 claims, followed once again by a 45-day break. This process repeats for up to 3 rounds, after which providers may be referred to CMS for follow-up if the error rate has not significantly improved.
What are the most common claim errors? Believe it or not the most common errors are the basics, such as:
The signature of the physician was not included.
Encounter notes did not support all elements of eligibility.
Documentation did not meet medical necessity.
Missing or incomplete initial certifications or recertifications.
Improper billing or payment that is more than an isolated incident is suspect, even when found to be the result of a knowledge deficit or other type of inadvertent error on the part of the facility staff. CMS and the Office of Inspector General (OIG) have made it clear that, in such cases, someone at the facility should have known, or should have wanted to know, about the improper billing practices in order to ensure that they were eliminated. Therefore, such practices are viewed as fraud or abuse and may be subject to civil monetary penalties or other criminal and civil enforcement activities. Regardless of the cause, owners and administrators should implement internal systems to routinely audit billing and Minimum Data Set (MDS) processes as well as all other components of Medicare and Medicaid reimbursement in order to detect and correct these kinds of problems quickly. The time to develop a corporate compliance program is now, before you are targeted for review. If you have a corporate compliance program but haven’t reviewed it in a while, do so. Sound billing practices are a lot less trouble than a stressful government review.
Written by: Elizabeth Johnson, Regional Vice President, Seagrove Rehab Partners
Reference for facts and statistics: AANAC’s Resident Assessment Coordinator—Certified (RAC-CT) education and certification program materials
CMS Q&A Document: https://www.cms.gov/files/document/updated-tpe-qas.pdf
Learn More: Watch this (surprisingly humorous at times) video from CMS, which gives a TPE overview…
About Seagrove Rehab Partners
Our aim is to serve the therapy industry by providing a compassionate, people-centered approach to compliance and management support, including a proprietary solution for SNF in-house therapy programs. Our In-House Therapy Alliance not only helps our partners to be more compliant and profitable, but also puts the patient first. Mark McDavid, president, and our company associates are available to work with skilled nursing facilities, rehab agencies, and other healthcare providers at the client site, by phone, by email, by video conference call and through workshops and seminars.
