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Targeted Probe and Educate Audits Are Here: Are you at Risk?

MAC’s, otherwise known as Medicare Administrator Contractors or fiscal intermediaries, are beginning to reach out to providers to inform them that they are being reviewed as a part of their new auditing process: Targeted Probe and Educate audits, otherwise known as TPE audits. Sounds unnerving, right? Do you know if you are at risk? We’ll tell you some of the behaviors that are landing providers into this group and what you can do to ensure you are prepared if you do receive word you are in one.

Providers with high denial rates or unusual billing practices or data that falls outside of the norms for that jurisdiction will be chosen for the TPE program in an effort to reduce claim errors and increase accuracy of billing. The MAC will notify providers if they are to be part of this program and will begin by reviewing 20-40 claims and supporting records as a “starting point”. If there are no concerning findings, they will not be reviewed for at least 1 year following the first round of the TPE program, however, if there are any denials there will be follow-up education sessions provided to the providers. The MAC will then allow a 45-day period to pass where providers can implement practices from the education provided and have a chance to improve their compliance before undergoing additional reviews.

So now that you know the premise of TPE audits- do you know if you are at risk? How do your billing practices compare to your peers within your jurisdiction? If you are an outlier- do you have the supportive documentation to support your claims? This is a great time to familiarize yourself with your PEPPER reports, specifically looking at: Rehab plus Hi-ADL’s, Non-therapy plus Hi-ADL’s, COT assessments, Rehab Ultra High, LOS exactly at 20 days or over 90 days.

Aside from having great clinical documentation to support your claims, you will want to avoid some common errors.

  • Signature of certifying physician not included: If past the window of remaining in compliance, do you need to obtain a delayed certification?
  • Documentation does not support medical necessity: Why does this resident require the services and inpatient stay we are providing?
  • Encounter notes do not support the elements of eligibility: Are you in compliance with your Local Coverage Determination (LCD)?
  • Missing or Incomplete Initial Certifications or Re-certifications: Missing info, lack of signature, incorrect dates will result in a denial.

Best practice to avoid these errors is to have a proactive approach to your triple check process that will encompass a documentation review. Technical denials are the most common, yet the “easiest”, errors to avoid. Familiarize yourself with your current billing and documentation practices and do an internal review to see how you would fare if you were part of a TPE audit. Based on your internal findings- begin your own education for your team to ensure that you have all the components in place to receive payment for the services you provide.


Written by: Kristi Smith, MSPT, RAC-CT, Regional Vice President of New England
Kristi's #HigherCalling: "I support those who constantly put others' needs first. Watching the pride on our staffs' faces as they achieve optimal outcomes and goals with our residents is priceless."

Tags: CMS Update 2018, TPE, Audits