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10 critical facts about the TPE program
The Centers for Medicare and Medicaid Services is ramping up its efforts to help providers and suppliers reduce claims denials and appeals through building out its Targeted Probe and Educate program. However, as the program hits its stride, providers should be worried about the potential for negative effects of the program, says Vasilios Nassiopoulos, vice president of revenue integrity and transformation for Hayes Management Consulting.

TPE focuses on improving accuracy in claims submissions, but the program—administered by Medicare Administrative Contractors—will use analytics to identify high claim error rates or unusual billing practices. Providers need to ramp up their use of technology and overall preparations to minimize the impact of TPE audits. Nassiopoulos assesses the potential pitfalls and highlights data and other practices that providers should follow.
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First, a little history
CMS began the TPE auditing program in 2017, designed to “help providers and suppliers reduce claims denials and appeals through one-on-one help,” seeking rapid improvement for organizations that consistently have errors in their Medicare billing submissions. The “targeted probe” part of the name should cause alarm, Nassiopoulos contends. The CMS is looking to mitigate apprehension about the program with a light and humorous video on their website. But don’t let the wit and whimsy fool you: this is a serious program with potentially costly consequences.
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Then, the basics of the program
If a provider is selected for the program, it will receive a letter from its MAC requesting 20 to 40 claims and supporting medical records. If it passes the review, it’s time to party—it will not be reviewed again for at least a year. However, organizations that fail will be invited to a one-on-one education session—it then will have 45 days to implement changes, after which it must submit another 20 to 40 claims for review. Fail that, get more education. Then claims submission round three happens; failure there means the organization will be referred to CMS for further action.
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Pray tell, what are the possible consequences?
According to Nassiopoulos of Hayes Management, CMS could take action after round three. Potential consequences include:

* 100 percent pre-payment review of all claims.

* Extrapolation of error rates from a sample of claims reviewed going back as many as six years.

* Referral to a Recovery Audit Contractor (RAC), which will have unfettered audit and extrapolation authority.

* Initiation of exclusion proceedings to terminate Medicare participation.

* Referral to Office of Inspector General for investigation and potential criminal prosecution of billing fraud.

In a word, ouch.
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Putting providers to the RAC
The criteria for data selection being used by RACs to identify audit targets is vague and has never been clearly communicated to providers. It appears they are looking for outliers, not only on overcoding but also on undercoding. They are also focusing on complex procedures, off-label drugs and multiple procedure codes for complex procedures to review the accuracy of clinical documentation, but the exact parameters have never been fully outlined. Past experience of provider organizations suggest that RAC review can be challenging and a test of clinical coding and documentation practices.
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TPE criteria are a bit vague
The CMS has not clearly outlined the review scoring methodology for the TPE audits or defined the passing percentage, Nassiopoulos contends. Providers don’t know if the reviewers are calculating scores based on a percentage of lines that have issues, or if one non-compliant line signifies failure for the entire claim as a whole. The lack of clear definitions for passing and failing grades is causing confusion.
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Education components may be inadequate
The program promises further education and training for a failed audit, but most of the training is general in nature and is provided remotely—either over the phone, via web conference, or through the mail, with documentation shared on Google Docs. Only on rare occasions is there an on-site visit. There is also concern over the strength of knowledge of the trainers, Nassiopoulos contends. “During several training sessions, a number of our clients have questioned some basic concepts, and the trainers struggled to provide adequate answers.”
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Ought the audit to be limited in scope?
The short answer is, apparently, no. Following a failure after a third round of training, reviews by the MACs and RACs are not limited in their scope. The process reverts back to a typical governmental auditing cycle, meaning they are not restricted as to what they can examine. They can go as far back as they want—even reviewing charts prior to the start of the TPE process. And the TPE is not restricted to one area—a provider organization can be subjected to multiple TPEs in different areas at the same time.
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Scout’s honor, providers need to be prepared
Nassiopoulos says the best defense against a TPE audit is to be prepared. An organization—and especially its compliance department—should incorporate TPEs into an annual plan and take them very seriously. The ultimate goal is to minimize the TPE audit to the first round.
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How to get ahead of the game
In addition to ensuring that data programs and documentation programs are performing optimally, Hayes Management suggests the following steps to anticipate what TPE requests might look like this year:

* Implement an aggressive pre-emptive auditing program to investigate and address possible risk areas.

* Review what CMS requested in 2018 in other audits and assess risk in those areas first.

* Examine historical data for any prepayment (precertification) and preclaim adjudication audits that CMS has performed.

* Review CMS explanations for denials and additional information the agency has requested.

* Look at historical data (not necessarily TPE related but also other prepayment reviews) that CMS has performed for the organization. Identify the trends and risks and insert them into the annual compliance plan.

* Focus on ensuring your coding and documentation integrity.
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Bring automation to the process
Collecting this data and performing these reviews manually can be a time-consuming, resource-draining process. A much more efficient way to handle the internal review is to leverage an automated audit platform that can streamline the process. Hayes Management has MDaudit Enterprise, a software solution for this purpose. But organizations should look to implement technology that helps collect and analyze data that reveals denial patterns, identifies potential risk areas and helps correct underlying issues to pass any first-round audits and avoid additional TPE rounds.