Highlights of Targeted Probe and Educate

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.

Tips for Success

All three Medicare MACs have the capability of receiving medical records for review by electronic submission. If your agency has not yet enrolled in the electronic submission of medical records, we recommend implementing that process as soon as possible. It is much easier to prove timely acceptance of the record when the record is submitted electronically to the MAC.

Both Home Health and Hospice should make sure that you have an organized process of checking for ADRs, including who has been assigned to clinically review the chart once it is assembled and that everything is included. Agencies really need to be successful in the first round and not be moved into the second round of review.

• Providers targeted for TPE have been receiving a notification letter about the review and additional development requests (ADRs) will be used for the specific claims selected for review.
• Providers should ensure that medical records are submitted promptly upon request.
• Providers nonresponse to medical records requests will count as an error – this can trigger an automatic escalation of review of your agency and potentially a referral to one of the other contractors mentioned above.