CMS Pub. 100-08, ch. 3, § 3.2.5

This section applies to MACs.

A. Overview

The purpose of Targeted Probe and Educate (TPE) is to decrease provider burden,

identify and prevent improper payments, reduce appeals, and improve the medical

review/education process.

This section describes requirements that MACs shall follow when performing medical

review as part of TPE.

TPE reviews can be either prepayment or post-payment and involve MACs focusing on

specific providers/suppliers that bill a particular item or service.

A round of TPE typically involves the review of 20-40 claims, per provider/supplier, per

service/item, and corresponding education. In rare circumstances, CMS may approve a

probe sample of other than 20-40 claims. This process is typically repeated for up to three

rounds, but may involve additional rounds at CMS direction. MACs discontinue the

process if/when providers/suppliers become compliant. Providers/suppliers who remain

non-compliant after three rounds of TPE are referred to CMS for further action.

B. Provider Selection

The MACs shall initiate a provider-specific, prepayment or post-payment review based

upon data analysis, as discussed in §3.2.1. MACs shall also initiate targeted, provider-specific, prepayment or post-payment review upon referral from the RAC,

Comprehensive Error Rate Testing (CERT), Unified Program Integrity Contractor

(UPIC), Office of Inspector General (OIG), or Government Accountability Office (GAO)

when directed by CMS. MACs shall target providers/suppliers who have historically high

claim denial rates, who have billing practices that vary from their peers, or when

evidence suggests that there is a potential risk to the Medicare Trust Fund.

Probe Selection

The MACs shall select probe samples of typically 20-40 claims. Probe samples of

different sizes may be deemed appropriate on a case-by-case basis, with approval by

CMS. The MAC should choose the volume of claims such that a round of reviews does

not take longer than approximately 6 months. In cases where the provider billing volume

initially supports a particular claim volume (to fulfill the 20-40 claim request) and that

claim volume subsequently decreases, MACs should consider closing the round with the

existing claims at the 6-month mark.

Provider Notification Letter

The MACs shall send a notification letter to providers/suppliers being targeted for review

that:

• Outlines the targeted probe & educate process,

• Explains the process by which providers/suppliers will be able to receive one-on-one education and the types of education that will be available,

• Notifies providers/suppliers that MACs shall have the option to refer

providers/suppliers to the RAC or UPIC as a result of non-response to Additional

Development Requests (ADRs), and

• Includes the following language to remind providers of 42 CFR §424.535

“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us to

revoke Medicare billing privileges under certain conditions. In particular, we note that

per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled

provider or supplier’s Medicare billing privileges if CMS determines that the provider or

supplier has a pattern or practice of submitting claims that fail to meet Medicare

requirements.”

C. TPE One-On-One Education

For the TPE process, one-on-one education is defined as teleconference calls, face-to-face visits, electronic visits using webinar technology, or other similar technologies that

enable direct communication between the MAC educator and the provider/supplier.

MACs shall record these activities in monthly reporting to CMS as well as document and

maintain the results of the education, and/or attempts for education, for data analysis and

possible future reporting.

Intra-Probe Education

The MAC may identify errors in the claim(s) that can be easily resolved during the

course of provider’s/supplier’s probe reviews. Easily curable errors include, but are not

limited to, missing documentation that can be resolved through the submission of

additional documentation and missing signatures that can be resolved with a signature

attestation. When the MAC identifies an easily curable error, the MAC shall contact the

provider to address the error and allow the provider to submit missing documentation,

etc.

Post-Probe Education

The MAC shall contact the provider/supplier via telephone (or face-to-face, electronic

visits using webinar technology, or other similar technologies as they become available)

to offer a one-on-one educational session after each round of probe review. If the

provider/supplier declines the offer for one-on-one education, MACs shall maintain a

record of the effort and the reason for denial. The purpose of this one-on-one education is

to:

1) Alert the provider of errors identified and how they may be resolved for future

claim submissions; and

2) Provide education regarding the review topic to help prevent new issues from

arising during future rounds of review. This post-probe one-on-one education

should be individualized, claims-specific, and conducted in a format that is

interactive, allowing the provider/supplier to ask questions as needed.

The MAC shall provide a minimum of 45 days after each post-probe educational session,

before selecting new claims for review, to allow time for the provider/supplier to cure

identified errors.

D. Post-Probe Activity

Final Results Letter

The MAC shall send the provider/supplier a letter detailing the results of the claims

reviewed at the conclusion of each round of review. The MAC shall include details

regarding the provider’s/supplier’s specific claim errors. For providers/suppliers who will

be released from review due to meeting the established error rate goal, results letters shall

indicate that the provider is being released from review for one year, with the caveat that

additional review may occur at any time should the MAC identified changes in billing

pattern. For providers/suppliers who continue to have high error rates after three rounds

of TPE review, results letters shall indicate that they have not met the established goal

error rate and will be referred to CMS for additional action, which may include additional

rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a

Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the

following language to remind providers of 42 CFR §424.535.

“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us

to revoke Medicare billing privileges under certain conditions. In particular, we

note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a

currently enrolled provider or supplier’s Medicare billing privileges if CMS

determines that the provider or supplier has a pattern or practice of submitting

claims that fail to meet Medicare requirements.”

Determining the Need for Additional TPE

The MAC shall calculate the provider/supplier claim error rate and payment error rate at

the conclusion of each round of TPE. The MAC shall use the provider/supplier error rate

to determine whether an additional round of TPE is appropriate.

Closure and Monitoring

A provider/supplier may be removed from TPE after any round if they demonstrate low

error rates or sufficient improvement in error rates, as determined by the MAC. MACs

shall use data analysis to monitor the providers/suppliers who have been discontinued

from the TPE process. MACs shall conduct follow-up review in one year or sooner if

data analysis indicates changes in billing patterns or when potential risk to the Medicare

Trust Fund is identified.

E. Referrals

If a provider/supplier continues to have a high error rate at the conclusion of three rounds

of TPE, the MAC shall refer to CMS for further action. Referrals shall include details

regarding the reason the provider/supplier was selected for TPE review, TPE review

results, results of appealed denials (to the extent available at the time of referral), any

education provided (or offered and refused), and any other relevant information that may

be helpful in determining appropriate next steps.

The MAC shall refer suspected fraudulent providers to the UPIC at any time during the

TPE process.

F. Next Steps

Once the MAC refers a provider/supplier to CMS, details are reviewed to determine if

additional action must be taken by the MAC. Additional actions that may be required

include, but are not limited to, additional rounds of TPE review, 100 percent prepayment

review, extrapolation, referral to a RAC, and/or referral for revocation. If CMS directs

the MAC to conduct an additional round of TPE review, the MAC shall send the

provider/supplier a notification letter indicating that an additional round of review is

required. These reviews shall be of claims with dates of service at least 45 days after the

prior round’s post probe education and after the provider/supplier has received the

aforementioned notification letter.