All MAC medical record reviews are replaced with three rounds of pre-payment or post-payment TPE. If the provider’s error rate remains high upon completion of the first round, then the provider is retained for the second and, potentially, a third round of review.
Providers with a continued high error rate after three rounds of TPE will be referred to CMS for additional action. The MAC will select the topics for review based upon existing data analysis procedures. The claim sample size for each round of probe review is limited to a minimum of 20 and a maximum of 40 claims.
TPE processes include provider specific education that will focus on improving specific issues without allowing other problems to develop along with an opportunity for the provider to ask questions. Education will be offered after each round of 20 to 40 claims reviewed.