Summary
Targeted Probe & Educate, a medical review process introduced by the Centers for Medicare and Medicaid Services in late 2017, identifies providers with high claim error rates or unusual billing practices for items and services that pose the greatest financial risk to Medicare. We present an overview of the process, which focuses on educating providers as a means of reducing claims denials.
Considering the current climate of heightened governmental scrutiny, it behooves anesthesia providers to familiarize themselves with the Centers for Medicare and Medicaid Services' (CMS's) new approach to medical review, known as Targeted Probe and Educate (TPE).
Piloted with one Medicare Administrative Contractor (MAC) a year ago, TPE was expanded to three MACs shortly after and to all MACs in late 2017. CMS has a lot riding on the program. More than $41 billion in incorrect payments were made through Medicare in 2016 alone.
Most clinicians will never be the subject of a TPE review, according to CMS, because the program zeroes in on providers and suppliers with high claim error rates or unusual billing practices as well as specific items and services with high national error rates that are a financial risk to Medicare.
Still, it is not out of the realm of possibility for anesthesia-related items to become TPE topics, as they have with CMS's Comparative Billing Reports (see our eAlert on the 2017 CBR for anesthesia for lower endoscopy) and the Office of Inspector General's Work Plan. This could, conceivably, increase your chances of becoming the subject of a TPE review. As a result, while ensuring that your practice fully complies with Medicare regulations, it's also a good idea to understand how TPE works.
TPE signals a shift by CMS from more time-consuming reviews of all providers who bill a particular item or service to reviews of a smaller representative sample of 20-40 claims for specific providers who bill that item or service and whose significant variance from their peers poses a potential risk to Medicare.
The modified approach is designed to make more judicious use of resources, reduce the time spent on medical review by Medicare-compliant clinicians (as part of the current administration's stated priority to reduce administrative burden), and reduce appeals—and the appeals backlog—by giving audited practitioners opportunities to learn and improve before their claims are denied. The program doesn't look for deficiencies in order to recover payments; it tries to help practitioners fix deficiencies in order to avoid denials.
TPE is implemented by the MACs, which analyze data to identify topics for review in their jurisdictions and pinpoint statistical outliers—practitioners with high claim error rates or billing practices that fall outside the norm. MACs choose specific CPT and HCPCS codes to audit based on analyses of codes that demonstrate the highest potential for fraud, abuse or error.
According to CMS, common claim errors include a missing signature of the certifying physician, encounter notes that do not support all elements of eligibility, inadequate documentation of medical necessity, and missing or incomplete initial certifications or recertifications.
A TPE initiated by MAC Novitas Solutions in January 2018 of CPT codes 99291 and 99292 (Critical Care, Evaluation & Management Services) identified the most common reasons for denials or partial denials to be: 1) insufficient documentation to support the level of care billed; 2) insufficient documentation to support the services billed; and 3) billing errors.
TPE consists of up to three rounds of (pre- or post-payment) reviews. The number of rounds depends on the results of each review. The MAC conducts an initial probe audit of 20-40 claims (per item or service) with one-on-one education before, during and after the review to give the provider a chance to improve.
Targeted Probe & Educate
For those who do not make the required improvements, the MAC follows up with a second probe audit of 20-40 claims. If the second probe reveals another high error rate, a third probe of 20-40 claims is conducted. Providers that fail the third probe are referred for further action, which could include reviews of all claims before payment, referral to a recovery audit contractor and other actions. If a probe reveals error-free claims and documentation in the sample, the process is discontinued for at least a year; however, the MAC continues to track the provider's claims to determine if an additional probe is needed after the one-year period.
After each review of 20-40 claims, providers receive a letter detailing the results, with an opportunity for individualized education via teleconference or webinar.
CMS reports that the TPE pilot conducted a year ago resulted in a significant drop in appeals and denial rates for the vast majority of providers as they progressed through the educational process.
As CMS moves forward with TPE, anesthesia providers should do everything they can to remain compliant and current on all local coverage determination policies and do their due diligence on documentation. Our hope is that this initiative will truly lighten anesthesia providers' administrative and regulatory burden.
ABC offers an array of services to help clients improve their documentation and remain compliant, including:
With best wishes,
Tony Mira
President and CEO