Important News: TPE Audits Resume

CMS resumes its targeted, probe and educate program.

The Centers for Medicare and Medicaid Services (CMS) announced that Targeted Probe and Educate (TPE) audits would resume on Sept. 1, 2021. TPE audits had been suspended by CMS during the public health emergency (PHE).  Unlike recovery audits, the stated goal of TPE audits is to help providers reduce claim denials and appeals with one-on-one education, focused on the documentation and coding of the services they provide.

A little history on these audits is in order.

Who conducts the TPE?  Medicare Administrative Contractors (MACs) conduct the TPE audits. This is your local Medicare carrier.

Why is CMS utilizing TPE audit?  CMS promotes the TPE audit program by stating that it has increased provider education which results in decreased error rates and appeals through the CMS administrative appeal process. 

What can be reviewed?  While originally limited in scope to hospital inpatient admissions and home health claims, CMS expanded the program in 2020, to allow MACs to perform TPE audits of all Medicare providers for all items and services billed to Medicare. 

Why are providers chosen?  Providers are usually chosen based on data analysis, such as high error rates in their billing practices in their submission of claims to the MACs or because they are outliers in their code utilization rates compared to their peers. However, providers can also be chosen for reasons unrelated to their own billing practices if they bill for items that have high error rates nationally.  CMS states that from October 2018 to September 2019, approximately 13,500 providers received a TPE notice of review and approximately 435,000 claims were reviewed. 

What is the TPE audit process? 

1. 1. Provider receives a “Notice of Review” letter from the MAC which states the reasons the provider has been selected for review and requests 20-40 records be produced. 
   2. Once the records are produced, the MAC will review the 20-40 claims against the supporting medical records and send the provider a letter detailing the results of their review. (Do not ignore these letters. They usually come in a pink envelope).
   3. If the claims are found to be compliant, the TPE audit is complete for that provider (physician, hospital, or QHP) and the provider cannot be selected for review again for a year unless the MAC detects significant changes in provider billing.

If the claims are found not to be compliant, the MAC will invite the provider to a one-on-one education session specific to the provider’s documentation and coding practices. The provider is then given 45 days to make changes and a second round of 20-40 records will be requested with dates of service no earlier than 45 days after the one-on-one education. 

4. Providers are given three rounds of a TPE audit to pass. If the provider fails pass after three rounds, they will be referred to CMS for further action.  The next steps can include actions such as 100 percent prepay review, extrapolation, referral to a Revenue Recovery Auditor (RAC), or other action.  

How does the MAC decide if you are pass a TPE round?  The MAC, Medicare Administrative Contractor, like Noridian or Novitas, can look at the Medicare Fee-For-Service improper payment rate for the specific item or service being reviewed and compare that to the provider’s error rate. The provider’s active participation in the education process and levels of improvement with each round are also taken into consideration. There must be a learning curve and transparent corrective action.

What are common mistakes identified in TPE audits? 

According to the CMS.gov website, and many MAC sites, the most common errors identified by CMS are as follows:  

• The signature of the certifying physician is missing – (this could be a manual signature or a missing authentication of an electronic record, or a missing counter signature for teaching physician claims (supervising physician).
• The encounter notes do not support medical necessity – (remember it is the payer’s definition of medical necessity for an item or service, not the physician’s).
• The documentation does not support medical necessity – (missing links from a presenting problem, and an ordered test or procedure).
• Missing or incomplete certifications or recertification documents – (this is a big one, as advanced diagnostics performed in a physician’s office have certification requirements for safety, as does OSHA). 

What can a provider do to prepare for a TPE audit?  If you are a provider that has received a TPE audit, the best defense begins immediately prior to sending the requested records. By sending complete and organized records during the first round of a TPE, the chances of passing are increased. 

In addition, implementing corrections efficiently and effectively after education is given to the provider also increases the chance of passing the TPE audit. A well-developed initial response to a TPE audit can make the difference between passing the audit or being referred to CMS for further action.  As the next steps can include onerous actions such as 100 percent prepay review, extrapolation, referral to a Recovery Audit Contractor (RAC), or other action, a carefully crafted response to a TPE audit is critical.  

Healthcare organizations should consider engaging outside counsel or a coding and billing consultant to help conduct the internal review so that the organization and counsel or consultant can form a defense strategy if they decide to challenge the TPE audit.

As part of the internal review, healthcare organizations should document when audits occur and what steps the organization has taken to address the issues that were part of the TPE audit. Healthcare organizations should also document if they’ve done training since the TPE audits. That is one area that is lacking in being proactive for TPE or any Medicare audit. Not letting your guard down once the audit is completed. The preparation for an audit should be ongoing, as you never know when you may get a request for an audit.

Programming Note: Listen to Talk Ten Tuesday today for more details on TPE Audits and how it may impact your practice and how to prepare.