By: Lorna Simons, CPC
Medco Consultants, Inc
Have you ever been caught in the avalanche of paperwork and uncertainty that is entailed with a Medicare appeal? Medicare audits are never a fun topic to discuss. They can at times be a long, drawn out processes. In an effort to “reduce appeals, decrease provider burden and improve the medical review and education process,” Medicare has expanded the Targeted Probe and Educate (TPE) pilot program to all of their Medicare Administrative Contractors (MACs) for Part A, B, HHH and DME.
How will this reduce the number of appeals?
The providers/suppliers will have one (1) to three (3) pre- or post-payment rounds of review. After or during each review, the healthcare provider /supplier will be educated based on MACs findings. The educational sessions are offered via webinar or telephone conference by a nurse reviewer. Other educational methods are available if necessary. If the healthcare provider/supplier is found to be non-compliant with Medicare, they will be reviewed again.
Only when the provider/supplier is found to be non-compliant following the third review, will they be referred to the Centers of Medicare and Medicaid services (CMS) for additional action. These actions include “extrapolation, referral to Zone Program Integrity Contractor(ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the RAC or 100% pre-pay review,” etc. (i.e. audit).
How will this decrease provider/supplier burden?
The MACs will be reviewing limited samples of 20 to 40 claims per review round. This will decrease the amount of documentation being sent out and ease the economic burden of being on 100% pre-payment review for providers/suppliers with high Medicare patient populations. After each round of audit and education, non-compliant providers/suppliers will have a minimum of 45 days to improve documentation and become compliant before the next round commences.
Source:
Targeted Probe and Educate (TPE) , http://ow.ly/JB5N30fDG7u
CMS PUB 100-20 One-Time Notification, Transmittal 1919, SUBJECT: Targeted Probe and Educate, http://ow.ly/sf9A30fDGjQ
NGS Compliance & Audits, Targeted Probe and Educate http://ow.ly/IshY30fDGyM
Noridian Healthcare Solutions, Targeted Probe & Educate http://ow.ly/s6HN30fDGLX