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Last Modified: 5/16/2019 Location: FL, PR, USVI Business: Part A, Part B

December 14, 2017 – Follow-up questions and answers

Targeted probe and educate: Reducing provider burden (A/B)

The following questions originated in the above listed event. The question is followed by the appropriate answer and applicable resources. For additional information or details, please refer to the Centers for Medicare & Medicaid Services’ TPE Q & As external pdf file document.
1Q. When will the Targeted Probe and Educate (TPE) review begin officially?
1A. As stated in change request (CR) 10249 external pdf file, the TPE process officially began October 1, 2017, initiating and transitioning from the progressive corrective action (PCA) to the TPE approach for First Coast.
2Q. What is the accuracy percentage benchmark for determining if a provider is compliant or non-compliant and moves to the next round of targeted probe and educate (TPE)?
2A. Each Medicare administrative contractor (MAC) will set the accuracy percentage benchmark individually and it may vary for each of the different topics/codes under review. There are many factors considered in determining these percentages and the next steps. The individualized summary letters will give the error rate and any additional follow up activities such as the next round of TPE.
3Q. Is First Coast starting prepayment TPE in 2018 or 2019?
3A. First Coast is currently conducting TPE on postpayment Part B claims only. We plan to begin prepayment TPE in March 2018 for Part A and Part B. Diagnosis related group (DRG) 885 (Psychoses) will be the first prepayment TPE topic for Part A. The first prepayment TPE topic of review for Part B is currently under consideration and will be determined based on data analysis.
4Q. What is the Direct Data Entry (DDE) reason code for the TPE?
4A. First Coast is currently conducting TPE reviews on post pay claims, which means the claim has already been processed and paid. On a post pay claim, there is no audit/reason code designation in DDE for TPE. When we begin prepayment TPE, there will be a prepayment audit/reason code in the system that will automatically generate a notification letter if you are selected for prepayment TPE. The prepayment notification letter will advise you of the services under review and the edit being implemented including the effective date.
5Q. Who does the provider contact at First Coast for TPE assistance?
5A. Your notification letter will include the contact name of the medical reviewer or analyst requesting documentation. For postpayment TPE, you will receive a telephone call for the medical reviewer to provide an introduction and to verify the address before the postpayment notification letter is mailed. When prepayment TPE begins, an introduction call will also be made before the notification letter is mailed that will also contain the contact person information.
6Q. When responding to documentation requests for TPE, do we use the same submission methods for responding as we’ve used in the past? Can providers respond to documentation requests under TPE via the Secure Provider Online Tool (SPOT)?
6A. Yes, all prior submission methods are still acceptable. The letter requesting documentation will provide options for responding to requests and it is recommended to include the TPE notification letter with the documentation submission. Also, refer to the First Coast article Responding to additional documentation requests (ADRs) for additional guidance.
Please keep in mind that responding via SPOT is available for prepayment documentation requests only. At this time, First Coast is conducting TPE on a postpayment review basis.
7Q. Will TPE requests be based on services for inpatient and/or outpatient services?
7A. The TPE process can be for any topic or service; however, all topics have not been chosen at this time as data analysis is still ongoing for upcoming years’ targeted areas.
8Q. Is the TPE process for wide spread edits?
8A. No, the purpose of the TPE process is to establish edits that are provider specific only based on data analysis.
9Q. If First Coast calls for introduction and is unable to reach the provider, how many additional call attempts will be made for introduction?
9A. First Coast will attempt to call one to two times for introduction. If we are attempting to schedule education following the probe, we will make three attempts by phone before sending a certified letter notifying you of the attempts to contact you. We will also include the date that the next round of TPE will be initiated.
10Q. How far back will the dates of services be for the postpayment TPE?
10A. First Coast wants to focus on more current dates of services so that education can be conducted on current documentation practices and medical policies. Contractors must follow the reopening of claims guidelines that can be found in the internet-only manual (IOM) 100-04, Chapter 34 Reopening and Revision of Claim Determinations and Decisions external pdf file.
11Q. Are the document requests on prepayment claims for the first, second or third round?
11A. The CMS does not require MACs to perform either pre- or postpayment for specific rounds in the TPE process. This is determined at the MAC level based on the type of services under review and whether a pre- or postpayment approach is more appropriate for the services being reviewed.
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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.