CMS has announced plans to expand the targeted probe approach to medical review to all MACs (Medicare Administrative Contractors). TPE includes processes for communication and education with providers that, historically, has been shown to help reduce errors. TPE will involve selecting review topics based on data analytics, and focus ADR activity on providers with the highest claim error rates or outlier billing practices.

Claim Selections:

TPE involves probe review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. After each round, providers are offered individualized education based on their review results.

Probe & Review Process:

Providers with moderate or high error rates will move on to additional rounds of 20-40 claim reviews which will again be followed by one-on-one education. Providers who have high error rates after round two will continue on to a third (and final) round of probe reviews and education. Providers who have shown continued high error rates after three rounds of TPE may be referred back to CMS for additional actions which may include 100% prepay review, extrapolation, or referral to other review contractors e.g. RAC or UPIC. If low error rates or sufficient improvements are observed however, a provider may be removed from the review process following any of the three rounds of probe review.

View the TPE Flow Chart

View Common TPE Q&A

Medical Review Preparedness and Response:

Robust Medicare Compliance Programs, strong auditing and monitoring systems, and an effective medical review response plan will help you to prepare for TPE. Proactive’s budget-friendly proven systems help to reduce risk and increase favorable audit outcomes.

Proactive Client ADR Success Rate = 90% VS Non-Client Peers with <40%

Contact us today for information on training, auditing, and medical review assistance services.