Have you been “welcomed” by your Medicare Administrative Contractor (MAC) into the CMS Targeted Probe and Educate Program (TPE) ? CMS rolled out the TPE program October 1, 2018 in order help providers and suppliers reduce claims denials and appeals through one-on-one help. The goal of CMS is to help providers “quickly” improve. The TPE process includes three rounds of “probing” of claims, and educating the provider on the findings.
Therapy providers are coming under the TPE review, particularly in private practice:
You were chosen for TPE review for Procedure 97530-therapeutic activities, direct (one on one) contact…..because recent data analysis examined billing history for therapy codes looking for highest paid providers in the most recent six months.
Therapy providers are being targeted for various codes including the new evaluation codes, therapeutic exercise, therapeutic activities, therapeutic activities performed in the same session as manual therapy, and neuromuscular reeducation. Therapy providers, per their “welcome letters” are being targeted because the data analytics indicate that the provider’s use of the code in question is higher than their peers. Although the TPE process has been underway since October, 2018 more details regarding program policy and implementation was added to the Medicare Program Integrity Manual. Some important facts about the Medicare Targeted Probe and Educate Program (from the Transmittal):
- A round of TPE typically involves 20-40 claims, per provider/supplier, per service/item, and corresponding education. This process is repeated up to three (3) rounds, and CMS may approve a different number in the probe sample.
- MACs discontinue the process if/when a provider is compliant. However, a non-compliant provider may be referred to CMS, the RAC or UPIC for further action.
- A round of education is defined as teleconference call, face-to-face visits, electronic visits using webinar technology.
- The paid claims error rate is calculated at the end of each round of TPE, and will be used to determine if additional rounds of TPE are needed.
For therapy providers who have been selected for TPE, the process has been somewhat challenging. Various codes, based upon data analytics, are selected for review per the individual provider (may be defined as group practice, rather than individual therapist). Are you prepared to respond to a TPE audit? Is your therapy documentation in order? Have all the requisite plans of care been properly certified? Have you profiled your practice to determine if you are a potential target? Contact us for assistance with a TPE audit response.