CMS Restarts Target Probe and Educate audits

Date: September 28, 2021

The Centers for Medicare & Medicaid Services (CMS) announced in an August issue of “MLNConnects” newsletter for the Medicare Learning Network that Target Probe and Educate (TPE) audits would resume again after being paused as part of the COVID-19 pandemic.

CMS notes on their TPE webpage the following:

CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.

They also note:

MACs use data analysis to identify:

  • providers and suppliers who have high claim error rates or unusual billing practices, and
  • items and services that have high national error rates and are a financial risk to Medicare.

Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.

CMS has produced a nice 3-page Q&A on the TPE rationale and process.  You can link to it here.  They note this type of audit “typically involves the review of 20-40 claims per provider/supplier, per item or service. This is considered a round, and the provider/supplier has a total of up to three rounds of review. After each round, providers/suppliers are offered individualized education based on the results of their reviews. Providers/suppliers are also offered individualized education during a round when errors that can be easily resolved are identified.”

We are available and happy to assist you with issues related to this type of audit as well as on many other issues related to eye care coding and reimbursement.  We are still available to present our webinars related to the significant changes for 2021 Evaluation and Management eye exam coding.  This new full program includes a large, completely revised text and new Office Visit Guide pocket guides, so contact us if you are interested.  Stay safe.

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