Medicare’s TPE Initiative:  What You Need to Know

Candace Lewis, Director, Revenue Cycle Management Revenue Cycle Management (RCM)

Medicare Target Probe and Education (TPE)

Medicare’s Target Probe and Education (TPE) is a new initiative of the Medicare Administrative Contractors (MACs) to review clinical documentation and prevent improper payments. The goal of the program is to help practices quickly improve by limiting the number of medical records requested for review and to emphasize education and assistance in correcting claim errors.

Not all providers will be a part of TPE. The MACs will use data analysis to identify providers who have high claim errors or unusual billing practices. Practices will also be targeted if the items and services provided have a high national error rate and are a financial risk to Medicare.

Some common errors the Medicare Target Probe and Education (TPE) program will focus on include:

  1. Signature of the certifying physician not being included
  2. Encounter notes not supporting all elements of eligibility
  3. Documentation not meeting medical necessity
  4. Missing or incomplete initial certifications or recertification

How the Medicare Target Probe and Education (TPE) program works

The MAC will select practices and if your practice is selected, you will receive a letter from your MAC. The MAC will review 20 to 40 of your claims and supporting medical records. If the medical records support what was billed, you will not be reviewed again for at least one year on the service that was audited.

However, if the documentation does not support the service being billed, the physician will be invited to a one-on-one education session. After the session, the physician will be given at least 45 days to make changes and improve, at that time another review of medical records will be performed. Once the re-audit occurs providers that do not have improvement after three rounds of education sessions will be referred to Centers for Medicare and Medicaid Services for next steps. The next steps could include 100 percent prepay review, or other action.

Recommendations

With this process in mind, it is suggested that practices have an audit performed to determine their risk level. Having to be involved in a prepay audit can cause significant financial issues for a practice.

For more information about this program, review the TPE FAQ.