The Centers for Medicare & Medicaid Services (CMS) announced Monday that it would start a new national audit strategy titled Targeted Probe and Educate (TPE) after pilot programs with four Medicare Administrative Contractors (MACs) demonstrated success. 

CMS described that success as “including an increase in the acceptance of provider education as well as a decrease in appealed claims decisions.”

According to CMS, the nationwide program “will select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate.”

“MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” the agency said. “These providers/suppliers and specific items/services are identified by the MAC through data analysis.”

In a process similar to that adopted recently for the short inpatient admission review process by the Quality Improvement Organizations (QIOs), the audit process “includes a review of 20-40 claims followed by one-on-one, provider-specific education to address any errors within the provider’s reviewed claims.”

“Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education,” CMS continued. “In addition to education at the conclusion of each 20-40 claim probe review, MACs also educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.”

This process is similar to what CMS has adopted for the QIOs to audit for short inpatient admission status, where the audits are directed at hospitals with a high percentage of short inpatient admissions or a high number of admissions of error-prone diagnoses, such as chest pain. But unlike the audits currently underway for short stays, the new TPE will allow three rounds of audits before referral back to CMS to consider further action, such as referral to the Recovery Audit Contractors (RACs) or pre-pay review.

Read the CMS announcement:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html