United States

Senior Living Health Care Connection: TPE program update

SENIOR LIVING HEALTH CARE CONNECTION  | 

Centers for Medicare & Medicaid Services (CMS) is moving forward with the targeted probe and educate (TPE) program to reduce claims denials and appeals. Medicare administrative contractors (MACs) have been tasked with determining which providers and suppliers who bill for particular services have the highest claim denial rates or who have billing practices that vary significantly from their peers. Letters are being sent to notify organizations that they have been selected based on CMS internal data analytics for the initiation of a review.

TPE involves a review of 20 to 40 claims per identified provider. The great majority of these reviews are pre-payment. Items being reviewed include physician certifications, unsupported medical necessity and unsupported encounter notes for utilization. The organization is then notified by letter of an additional development request (ADR) for certain records. Organizations can also check the direct data entry (DDE) system for suspended claims with type SB6001, SB6098 and SB6099 in the status/location (S/LOC) field. The organization is given 45 days to send the documents.

The review process starts with a letter from your designated MAC; your organization will then be notified of the 20 to 40 claims that require additional documentation. If all claims are found compliant then there will be no further review for one year. If some claims are denied, the provider will be invited to participate in a one-on-one education session. The review can include up to three rounds of review. If there is no improvement after the three rounds of review the organization will be referred to CMS for next steps, which may include 100 percent prepay review and referral to a recovery auditor. Visit the CMS site for additional information.

Questions? Contact Joan McCarthy at +1 312 634 3479.

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