While a TPE audit is typically comprised of up to three rounds, additional rounds could occur at CMS’s discretion. The Provider has the right to appeal any denied claims.Īn additional round of TPE review may only review claims with dates of service at least 45 days after the previous round’s one-on-one education session, thus providing the Provider an opportunity to incorporate the changes learned during the previous round’s education session. At the end of the round, the MAC calculates the Provider’s claim error rate to decide whether an additional round of TPE is appropriate. The Provider also receives a “Final Results Letter” from the MAC before or after the education session. If the MAC denies any claims, the Provider is invited to a one-on-one education session where the MAC reviews the improper claims and provides education on how to correctly bill for the specific items or services that were improperly billed. Once the Provider submits the supporting medical records for the selected claims, the MAC reviews and determines whether the Provider is compliant. TPE audits start with the receipt of a “Notice of Review” letter from a Provider’s MAC requesting 20-40 claims for each healthcare item or service under review. Medicare Administrative Contractors (MACs) target Providers identified through data analysis as having high claim error rates or unusual billing practices compared to their peers. During TPE audits, Providers are subject to up to three rounds of claims reviews (both pre-payment and post-payment) and individualized education. Targeted Probe & Educate (TPE) Program AuditsĪs the name suggests, TPE audits are intended to educate Providers on specific billing issues to increase accuracy and reduce claim denials and appeals, but they can also result in penalties. Understanding the different audit types can decrease the administrative burden and costs on a Provider when they are inevitably faced with an audit. While these audits are the most common, Medicare and Medicaid Providers may encounter other audits, including audits conducted directly by CMS’s Center for Program Integrity and quality of care-related audits by quality improvement organizations (QIOs) and state agencies. Comprehensive Error Rate Testing (CERT) audits.Supplemental Medical Review Contractor (SMRC) audits.Unified Program Integrity Contractor (UPIC) audits.Targeted Probe & Educate (TPE) Program audits.Types of CMS Contractor AuditsĬommon types of Medicare and Medicaid audits include: A significant area of government scrutiny includes claims reviews by the Centers for Medicare & Medicaid Services (CMS) and its audit contractors to ensure CMS accomplishes its stated mission for program integrity to “prevent, detect and combat fraud, waste and abuse in the Medicare and Medicaid Programs.” A key component of CMS’s program integrity efforts includes different types of program integrity audits, often run by third-party government contractors. In future installments, we will discuss how to best respond to audits, the potential ramifications of negative results, and how to appeal negative audit results.Īs discussed in the Bass, Berry & Sims Healthcare Fraud & Abuse Review, healthcare providers and suppliers (Providers) face increased government scrutiny from whistleblower lawsuits under the False Claims Act and government regulators pursuing civil and criminal healthcare fraud enforcement. This alert – the first in a three-part series – explores the different types of audit contractors and their respective scopes of work to assist providers in identifying the contractors, the mechanics of their specific requests, and the issues they present. Providers, therefore, should be prepared to identify and promptly and diligently respond to any audit requests from government contractors. Because Medicare and Medicaid claims audit requests can look like routine billing-related correspondence, they can be easy to miss, leading to expensive and potentially catastrophic consequences.
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