The goal of the TPE program is to reduce provider burden by helping Medicare providers / suppliers quickly improve accuracy and reduce claim denials and appeals through increased one-on-one education.

The key elements of this probe and educate include:

• Provider reviews typically consist of up to three rounds of a prepayment or post-payment TPE probe review. First Coast will select the topics for review and providers, based on existing data analysis procedures outlined in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
• First Coast will notify providers in writing of the topic being reviewed, the reasons for selection which will be supported by data analysis, and the process of review.
• First Coast may refer providers / suppliers to the RA contractor or to the Unified Program Integrity Contractor (UPIC) if providers do not respond to additional documentation requests (ADR).
• Education will be offered to the selected provider throughout the TPE process. Additionally, at the end of each "round of reviews," First Coast will provide notification in writing of the results of the claim reviews and education on the errors identified. Providers with a significant or high error rate will receive an offer for one-on-one education related to the specific errors identified. The goal is for providers to learn from the education and improve their claim review results in the next "round of reviews" and to achieve no errors or a low error rate classification.
  • Providers will be moved to another round of review if the error rate remains at a significant or high error classification.
  • Once a provider has reached a zero or low error classification, they will be removed from review of that service and First Coast will continue to monitor their claims data on a proactive, routine basis.
• Providers with a continued significant or high error classification after three rounds of prepayment TPE reviews will be referred to CMS for possible further action.

If selected for a TPE review, providers are not excluded from other medical review activities such as automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies, etc. as directed by CMS or other contractor reviews. Additionally, First Coast will continue to work with other CMS contractors and collaborate with referrals back and forth to the Quality Integrity Organization (QIO) for quality-of-care concerns, the UPIC for concerns related to potential fraud and/or abuse, and the RA contractor to ensure there is no duplication of reviews.