On August 17, 2018, the Centers for Medicare and Medicaid Services (CMS) announced that it is adding a sub-section (3.2) into Chapter 3 of its Medicare Program Integrity Manual (MPIM, Publication 100-08) entitled “Verifying Potential Errors and Taking Corrective Actions,” The new section references Medicare’s Targeted Probe and Educate (TPE) Program, first initiated as a pilot in 2016. The initial pilot focused only on nursing home and inpatient claims. The pilot has now been expanded to a permanent program which encompasses all claim types and can occur as either a pre-payment or a post-payment audit.

TPE audits subject providers and suppliers to up to three rounds of medical reviews. Claims are selected through data analysis. MPIM, Subsection 3.2 states:

“MACs shall target providers/suppliers who have historically high claim denial rates, who have billing practices that vary from their peers, or when evidence suggests that there is a potential risk to the Medicare Trust Fund.”

The MACs have the discretion to select target areas because of:

  • High volume of services;
  • High cost;
  • Dramatic change in frequency of use;
  • High risk problem-prone areas; and/or,
  • Recovery Auditor, CERT, Office of Inspector General (OIG) or Government Accounting Office (GAO) data demonstrating vulnerability. Probe reviews are not required when targeted areas are based on data from these entities.

Claims determined to be in error result in a provider’s notice of adverse determination and education from their MAC prior to the initiation of the next round of the TPE audit. Providers may, at their discretion, appeal TPE audit results, and this process mimics the standard Medicare appeals process.

Continued claims errors after three (3) rounds of TPE audit may be referred to CMS for further disciplinary actions. Subsection 3.2 also states:

“The MAC shall refer providers/suppliers for potential escalation to CMS at their discretion after three rounds of TPE review. Referrals shall include details regarding the reason the provider/supplier was selected for TPE review, TPE review results, any education provided (or offered and refused), and any other relevant information that may be helpful in determining appropriate next steps. The MAC shall refer suspected fraudulent providers to the Unified Program Integrity Contractor (UPIC) at any time during the TPE process.”

Given the potential impact of escalation outcome, and burden on providers with this programs continued emphasis, it is vital that providers carefully weigh the value of appealing adverse determinations when there is a valid justification to do so.  Personnel responsible for the review and response to adverse determinations must take immediate action by way of either internal education and corrective action or appeal the findings without delay. Regardless of which step a provider takes, immediate action will ensure that the provider is being paid the right services in an amount which it is legally entitled to receive every time.

For more information on the Targeted Probe and Educate Program, please contact Linda Mancini at (781) 272-8001.