UPDATED: October 6, 2017
In October 2017, the TPE Pilot is now open to all four DME MAC Jurisdictions. Suppliers will be chosen based on the following criteria:
- Items that pose the greatest financial risk to the Medicare Trust Fund – HCPCS with high national error rates, high dollar equipment, etc.
- Individual suppliers with high error rates
HCPCS that were currently under widespread prepayment reviews will likely be the first group included in the TPE selection.
Lastly, the goal of the TPE program is to eventually replace all other DME MAC audits, meaning widespread prepayment and documentation reviews will eventually be phased out entirely.
ORIGINAL PUBLICATION DATE: August 23, 2017
In recent months, the CMS has been touting its new “provider friendly” approach, which is, in part, a way to decrease the ever-mounting appeals backlog. And they have introduced several initiatives to do just that, including limiting the scope of review of Redeterminations and Reconsiderations and adjusting serial claims found favorable in the appeals process. The next item on the list, however, may be positive or negative, depending on what side of the coin you fall on. Let me explain.
The DME MACs have recently began to roll out the Targeted Probe and Educate (TPE) Pilot program. Beginning on July 3, 2017, CMS authorized the DME MACs to conduct the Targeted Probe and Educate (TPE) Pilot review process. This pilot is currently open to Jurisdictions B and D DME MACs. TPE includes up to three rounds of supplier-specific prepayment probe reviews followed by education to improve identified errors. The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education.
Suppliers chosen for the TPE program can expect the following:
- DME MACs will utilize data analysis to select the suppliers in the probe. The identified suppliers will receive written notification that will include the topic being reviewed, data reasons for the selection and the process of the review.
- The first-round prepayment probe review will begin following notification to the supplier. The DME MAC will request 20 – 40 claims for audit.
- Suppliers with a high error rate on their prepayment probe review will receive an offer for one-on-one education relative to the specific errors identified through the probe review.
- Following education, suppliers are expected to make necessary adjustments/process changes with sufficient improvement. This will be demonstrated through a second round of claim reviews to occur several months later during a second-round probe review. The probe review will again contain 20 – 40 claims for audit.
- If improvement in the second-round probe review is not sufficient, suppliers will undergo another round of education followed by another probe review.
- Following three rounds of probe and education, suppliers that do not demonstrate sufficient improvement in their error rate will be referred to CMS for possible further action.
- Once a supplier has reached an acceptable error rate, the TPE process will end and the DME MAC will notify the supplier of successful completion.
It’s important to note that if selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other pilot review programs, prior authorization, etc. as directed by CMS or other contractor reviews.
The DME MACs have indicated that if a high error rate persists following the maximum rounds of review and education, they will refer the supplier to CMS for possible further action. What does that include? Referrals to the ZPIC/UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to ensure there is no duplication of reviews.
One thing that is missing from the published articles and TPE letters: The potential for revocation of your Medicare supplier number. The Final Rule, effective December 3, 2014, states in part that, under authority of the ACA, CMS can and will deny or revoke enrollment of entities and individuals that pose a program integrity risk to Medicare for “… providers and suppliers that have a pattern and practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program. “We saw contractors start adding this language into overpayment demand letters over the past year, which leads us to believe they would eventually like to use this as a tool to suppliers they feel pose too much of a risk.
Now more than ever, suppliers must be vigilant in the claims they submit to Medicare. Documentation should be reviewed prior to claim submission to ensure the LCD guidelines have been met. It is also necessary to educate your staff – from intake to billers. If you are selected for the TPE program you will be required to present documentation that supports the medical necessity for the equipment provided. Be sure that you have what you need to be considered “compliant” in your billing practices. TPE allows you three chances to “get it right”. Then you could face extrapolations, RAC audits that go back three years, or worse, revocation.
Data analysis will look for high error rates, high reimbursement dollars, and top billers by area. Don’t wait for the DME MAC to send you a letter advising that you are a chosen participant in the TPE pilot. Taking a proactive approach could save your business. The van Halem Group can help. We offer a variety of proactive services that will identify issues, educate your staff, and help you make the necessary corrections going forward. Don’t wait until you get the TPE notification letter.