Last Modified: 2/1/2019
Location: FL, PR, USVI
Business: Part A, Part B
The Centers for Medicare & Medicaid Services (CMS) utilizes Medicare administrative contractors (MACs) to review clinical documentation in order to prevent improper payments. MACs may choose claims for review based on many different factors, such as widespread service specific improper payment rates, data analysis, and the billing patterns of providers. CMS is cognizant that this type of review can be burdensome to providers and is continuously working to improve the process.
In 2014, CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy targeted probe and educate (TPE). CMS believes that the results of this program have been favorable, based on the decrease in the number of claim errors after providers received education. CMS has now authorized First Coast Service Options (First Coast) to conduct reviews utilizing a TPE review process.
When you are selected to participate in the TPE process you will receive a notification letter. The notification letter will provide all the details of the new process, including the specific services under review, as well as a contact person for your office to speak with. First Coast suggests that you designate a point of contact; this will help your office to navigate through the process successfully. We will select for review a sample of claims on either a pre-payment or post-payment basis. Once all records of the sample have been received and reviewed, an error rate calculation if applicable will be made based on dollars denied. A detailed summary letter will be mailed describing any issues or errors. First Coast will then offer to provide one-on-one education regarding findings and denial reasons. The review summary letter will also contain contact and scheduling information for the education.
The TPE process may include up to three rounds of probe and educate, with each round allowing the provider time to correct any identified issues before the next round begins. If improvements are not made, First Coast will refer the provider/supplier to CMS for additional actions, which may include 100 percent prepay review, extrapolation, referral to a recovery auditor, etc. If during the review process minor errors are noted, the clinicians may contact your office for intra probe education to correct issues immediately and prevent future denials for the same reasons. The goal is for providers to learn from the education and improve their claim review results.
Some important things to remember include the following;
• Targeted probe and educate only replaces the medical review progressive corrective action process. You will continue to receive records requests applicable to claims processing (e.g., unlisted procedure codes, modifiers that require documentation, possible exact duplicate claims, etc.)
• Targeted probe and educate does not prevent or replace systematic automated reviews such as diagnosis to procedure and utilization reviews.
• The guidelines and timeframes for record submissions have not changed.
• You are still required to respond to records requests from other programs and contractors such as Comprehensive Error Rate Testing (CERT), quality improvement organization (QIO), recovery contractors, and the Office of the Inspector General (OIG).
• There are no changes to the appeals process.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.