At Nicholson & Eastin, LLP, we recognize the importance of staying up-to-date with the evolving healthcare regulations, including initiatives like the Targeted Probe & Educate (TPE) program introduced by the Centers for Medicare and Medicaid Services (CMS).
The Centers for Medicare and Medicaid Services have replaced the Progressive Correction Action or PCA with Targeted Probe & Educate or TPE. The TPE program aims to assist healthcare providers in reducing claim denials and improving compliance through personalized one-on-one assistance.
What is the TPE?
Targeted Probe & Educate (TPE) is a program established by the Centers for Medicare and Medicaid Services (CMS) to assist healthcare providers in improving their claim submission practices and reducing claim denials. Under this program, Medicare Administrative Contractors (MACs) conduct targeted reviews of medical claims and supporting records for selected providers. The goal of TPE is to identify potential compliance issues and errors in claims, and then provide one-on-one education and support to help providers address and rectify these issues. The program aims to enhance providers’ understanding of Medicare guidelines and policies, ensuring accurate reimbursement and promoting efficient and compliant billing practices.
What is the Goal of the TPE?
The goal of TPE is to help providers improve as quickly as possible. Medicare Administrative Contractors or MACs will work with them, in person to pinpoint errors and support in correcting them. Some of the most common errors that can be easily corrected include:
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- Missing Physician’s Signature: Ensuring that all medical claims include the necessary physician signatures is critical for compliance and proper documentation.
- Insufficient Documentation: Complete and accurate documentation is essential to support the medical necessity of services rendered and avoid claim denials.
- Missing or Incomplete Initial Certifications or Re-certification: Proper certification and re-certification of services are crucial for Medicare reimbursement.
- Encounter Notes that Do Not Support All Eligibility Elements: Detailed encounter notes are essential in demonstrating that the provided services meet all eligibility criteria.
Who is Targeted by the TPE?
The Targeted Probe & Educate (TPE) Program targets healthcare providers and medical suppliers who have a higher likelihood of claim errors based on data analysis. Medicare Administrative Contractors (MACs) focus on providers and suppliers that exhibit the following characteristics:
- High Claim Error Rates: Entities with a history of submitting claims with a higher-than-average error rate may be selected for TPE. These errors could include missing information, insufficient documentation, or other inaccuracies in claims submissions.
- History of Denials: Providers and suppliers that have experienced denials in response to Additional Documentation Requests (ADRs) may be targeted for TPE to address recurring issues and prevent future denials.
- Billing Practices Outliers: Entities that follow billing practices significantly different from similar healthcare providers in terms of volume or patterns may undergo TPE to ensure proper compliance with Medicare policies.
- Items/Services with High Error Rates: Healthcare agencies offering items or services that have a history of high overall national error rates and pose a financial risk to the Medicare program may also be subject to TPE.
It’s important to note that the TPE Program aims to help providers improve their compliance and billing practices rather than solely reprimanding non-compliance. The selection process is data-driven and seeks to identify areas where providers can enhance their claims submission process to reduce errors and ensure accurate billing practices.
What are the Benefits of the TPE Program?
The Targeted Probe & Educate (TPE) Program offers several benefits for healthcare providers and medical suppliers:
- One-on-One Assistance: TPE provides personalized feedback and education to providers, offering them the opportunity to understand and correct errors in their claims submission process. This direct engagement helps providers improve their compliance and billing practices effectively.
- Reduced Claim Denials: By identifying common errors in claims, TPE helps providers rectify these issues promptly, leading to a reduction in claim denials. This, in turn, results in improved cash flow and financial stability for healthcare entities.
- Improved Compliance: The TPE Program helps providers adhere to Medicare policies and guidelines, reducing the risk of non-compliance and potential penalties. By gaining a deeper understanding of Medicare requirements, providers can ensure accurate and compliant billing practices.
- Avoidance of Further Audits: Successfully completing the TPE process and implementing the necessary improvements can prevent providers from undergoing more rigorous audits, such as those conducted by Recovery Audit Contractors (RACs).
- Better Patient Care: Streamlining the claims submission process and avoiding denials allows healthcare providers to focus on delivering high-quality patient care without the burden of administrative issues.
Overall, the TPE Program facilitates a collaborative approach between Medicare Administrative Contractors (MACs) and providers, fostering continuous improvement and ensuring the integrity of the Medicare program.
How the TPE Process Works
If a provider is chosen for TPE, they will receive a letter from the MAC. The MAC will review 20 to 40 of the provider’s medical claims and supporting medical records. In the event a provider is compliant, they will not be reviewed again for at least a year on the selected topic.
If there is a denial of some claims, the provider will be invited to a one-on-one education session. The one-on-one education session will likely be held via webinar or teleconference and walk through any errors in the 20 to 40 of the provider’s reviewed claims. Providers will also receive the chance to ask questions regarding their claims and CMS policies that apply to the services or items that were reviewed.
After the one-on-one education session, they will be granted a 45-day period to make changes and improve. After the 45-day period, the MAC will again review 20 to 40 medical claims and supporting medical records, and the process repeats.
What Happens If Claims Do Not Improve
Fortunately, the majority of providers that have participated in the TPE process have successfully increased their claim accuracy. However, if providers fail to improve after three education sessions, they will be referred to CMS for next steps, which may be 100 percent prepay review, extrapolation, or a referral to a Recovery Auditor.
Contact Nicholson & Eastin, LLP for TPE Guidance
It is important for healthcare professionals to treat TPE as seriously as they would treat any other governmental audit. The attorneys at Nicholson & Eastin, LLP encourage providers who receive TPE notification letters to reach out right away. We can help guide providers with responding and without disrupting the productivity and workflow of their practice. Contact us, today.