APMA News - March/April 2020 - 38

Reimbursement
By Jeffrey D. Lehrman, DPM

Targeted Probe and Educate
In August 2017, CMS announced that the Medicare Administrative Contractors (MAC) had implemented a new initiative, Targeted Probe and Educate (TPE), to review clinical
documentation to prevent improper payments. The intent of
this initiative is to reduce claims submission errors through a
process of claims review and provider education. In this article,
we'll provide some background on the initiative and how it
works in practice.

Program History
CMS implemented a Probe and Educate pilot program several years ago to review a sampling of claims and educate providers to reduce submission errors. CMS noted a decrease in
appealed claims decisions as a result of the pilot program.
Therefore, CMS decided to expand this program to all Medicare
jurisdictions late in 2017.
Initially, a broad probe-and-educate program was used.
However, based upon its experience with the pilot program,
CMS is now moving toward a more targeted initiative. MACs
will carry out this initiative using the following protocol:
Focus on specific providers/suppliers for a service, rather than all providers.
20-40 claim reviews to be included in each round.
◆ CMS has authorized the MACs to conduct a 10-claim
preview in the first round in addition to the normal
TPE process. This preview is intended to reduce the
burden for compliant suppliers.
After the MACs tabulate the results of the reviews, they
will offer providers individualized education.

who, based on data analysis, are already submitting claims that
are compliant with Medicare policy." Providers/suppliers may
be removed at any point in the review process if they demonstrate low error rates or sufficient improvement in error rates,
as determined by the MAC.

Review and Education Process (for those selected)

* The MACs' initial review of 20-40 claims will be fol*
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Basis for Claims Selection

* Items/services posing greatest financial risk to the Medicare trust fund
Claims
that have high national error rates
*
Billing
practices
that vary significantly from those of
*
providers' peers

Medicare carriers will conduct data analysis to select providers/suppliers and specific items/services.
According to the CMS announcement in August 2017, the
claim selection attempts to eliminate burden on "providers
38 APMA News March/April 2020

lowed by one-on-one provider-specific education addressing errors in the reviewed claims.
Providers/suppliers with moderate and high error rates
will be obligated to undergo a second 20-40 reviews
followed by additional provider-specific one-on-one
education.
Providers/suppliers with high error rates after the second
round will continue to a third and final round of reviews
and education. The MACs may refer providers/suppliers
with continued high error rates after three rounds of TPE
to CMS for additional action, which may include 100percent prepay review, extrapolation, referral to a Zone
Program Integrity Contractor or Recovery Auditor Contractor, or other action.

Guidance
APMA suggests that members familiarize themselves with
the TPE process and attempt to avoid common claims errors
that may place them at greater risk of being selected for a probe.
Common errors include:
signature of the certifying physician not included;
documentation does not meet medical necessity or coverage criteria;
missing or incomplete initial certification or recertification;
documentation not received in response to the Additional Documentation Request letter; and
claim is the same as or similar to another claim on
file.
n

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Contact APMA's Health Policy and Practice Department with additional questions. Email healthpolicy.
hpp@apma.org.

APMA News - March/April 2020

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