TPE – TARGETED PROBE & EDUCATE: A CMS MEDICAL REVIEW STRATEGY
On 8/14/17, CMS announced that it will expand Targeted Probe and Educate (TPE) program to all MAC jurisdictions later in 2017 in order to identify potential Medicare fraud and improper payments. The TPE program began in 2014 as a means for CMS to review clinical documentation, combining a sample of claims with education, to help reduce errors in the claims submission process. Believing the results of that tactic were so successful, CMS initiated a targeted probe in one MAC jurisdiction in 2016, and then expanded into three MAC jurisdictions in July 2017.
TPE will focus on claims that carry the greatest financial risk to the Medicare fund, and/or on those providers who have the highest claim error rates and irregular billing practices when compared to their peers. In simple terms, this means that TPE claim selection will be provider specific, rather than being based on all providers billing a particular service. This selection will be accomplished by mining data from Medicare claims.
The TPE process will consist of a maximum of 3 rounds:
Round 1: Includes a review of 20-40 claims, followed by one-on-one, specific education based on the issues. Providers with moderate/high error rates will continue on to another targeted review.
Round 2: Includes 20-40 more claims, followed by further one-on-one education. Providers with high error rates after round two, continue on to a final round.
Round 3: Same process as noted above. Providers with a consistently high error rate after the third round will be referred to CMS for additional action, which may include the following: 100% Prepay Probe, Extrapolation of error rates to determine overpayment, or referral to the Recovery Audit Contractor (RAC).
What are some of the “red flags” that might be construed as indicative of “false claims”?
• Short qualifying hospital stays with extended RUG utilization
• Increase in Ultra High billing without evidence that the SNF population has changed
• Weak Primary Medical Diagnosis coding, especially when Ultra High and Very High RUGs are billed
• RUA or RVA scores for more than 30 days• High percentage of assessments falling exactly on or within 10 minutes of the RV and RU threshold
• PT, OT or ST claims with poor or missing treatment diagnosis codes to support the billed services
It is therefore most essential to establish strict protocols, and/or revise your existing procedures to ensure on-going and proper review of all billing and coding to reduce the risk of a targeted probe.