Targeted Probe and Educate (TPE) Medical Review Strategy

Targeted Probe and Educate (TPE) Medical Review Strategy

October 4, 2019 0 By Ronny Jaskolski


The Centers for Medicare & Medicaid Services
(CMS) utilizes Medicare Administrative Contractors or MACs like NGS to review clinical documentation
in order to prevent improper payments. The MACs then choose claims for review based
on many factors such as the service specific improper payment rate,
� data analysis � and billing patterns of the provider. � CMS recognizes that this type of review
can be burdensome to providers and they are always working to improve the process. Today we will discuss a new process designed
to ease the burden for providers. It is called Targeted Probe and Educate and
it is a new strategy that the Medical Review Staff will be using to review claims. � In 2014 CMS began a program that combined
a review of a sample of claims with education to help reduce errors in the claims submission
process. � CMS called this medical review strategy,
Probe and Educate � CMS believes results of this program have
been favorable, based on the decrease in the number of claim errors after providers received
education. � Therefore CMS is now further improving
this strategy by moving from a broad Probe and Educate program to a more targeted approach
that should reduce provider burden � When performing medical review as part
of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on
specific providers/suppliers within the service rather than all provider/suppliers billing
a particular service. � The MACs will select claims for items/services
that pose the greatest financial risk to the Medicare trust fund and/or those that have
a high national error rate. � MACs will focus only on providers/suppliers
who have the highest claim error rates or billing practices that vary significantly
from their peers. � These providers/suppliers and specific
items/services are identified by the MAC through data analysis. � TPE claim selection is different from
that of the previous probe and educate programs. Previously the first round of reviews were
of all providers for a specific service. The new TPE claim selection is provider/supplier
specific from the onset. This eliminates burden to providers who, based
on data analysis, are already submitting claims that are compliant with Medicare policy. � The TPE review and education process includes
a review of 20-40 claims followed by one-on-one, provider-specific, education to address any
errors with in the provider�s reviewed claims. � Providers/suppliers with moderate and
high error rates in the first round of reviews, will continue on to a second round of 20-40
reviews, followed by additional, provider specific, one-on-one education
� Providers/suppliers with high error rates after round two will continue to a third and
final round of probe reviews and education � In addition to education at the conclusion
of each 20-40 claim probe review, MACs also educate providers throughout the probe review
process, when easily resolved errors are identified, helping the provider to avoid additional similar
errors later in the process. CMS created this flow chart as a visual aide
to demonstrate the process of Targeted Probe and Educate, the results of the probe will
determine if education and additional probes are necessary. If an additional round of probe and educate
becomes necessary the MAC will allow time for the provider to cascade educational materials
to staff and revise any processes as necessary. You can access all this information including
the chart we just showed you on the CMS website. This is the information that CMS released
to all providers recently. Other websites may have different information
but this is the official announcement. You may also want to visit the NGS website
where we post Local Coverage Determinations and additional information about the Medical
Review Process If you have been selected to participate in
TPE you will receive a formal notification letter
If at any point you do receive a request for medical records be sure to answer that request
timely. NGS offers a free, secure web-based application
called NGSConnex . This service provides access to a wide array of self-service functions
that can help save you time and money National Government Services recommends using
our secure web based application NGSCONNEX to submit your Additional Documentation Requests. This application is a free service that is
available to our provider community 24 hours a day, 7 days a week. It allows you to submit your letters along
with the medical records instantly to NGS via a secure connection. CONNEX also reduces your financial burden
by eliminating shipping costs and staff time required to print and prepare the records
for mailing. Visit our website www.ngsconnex.com to register
for NGSCONNEX. You can also browse our YouTube channel for
instructional videos on how to use NGS CONNEX. Thank you for watching this Probe and Educate
Video. Stay tuned to the National Government Services
YouTube channel for more educational opportunities, designed for you.