This is the first of a regular monthly column authored by Alicia Cantinieri, managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group.

The Medicare Part A Targeted Probe and Educate (TPE) program is a compliance initiative developed by the Centers for Medicare and Medicaid Services (CMS) and conducted by Medicare Administrative Contractors (MACs) that aims to improve billing accuracy and reduce improper payments.

The MACs use data-driven analysis to identify providers whose claims exhibit higher-than-average error rates, unusual utilization patterns, specific services or billing categories with high national error rates, or that pose financial risks to Medicare. These providers are then selected for review. Many providers currently under a Part A TPE are facilities that had high error rates in the SNF 5-Claim audits mandated by CMS in May 2023 and began in June 2023. 

How the TPE Process Works

The TPE process consists of up to three rounds of medical review, each followed by provider-specific education when claim errors are identified. Once selected, the provider receives a notification letter explaining the reason for the review and the claims or services under review.

Following the initial notification, the facility will receive Additional Documentation Requests (ADRs). These requests identify the beneficiary, dates of service under review, required supporting documentation, and the due date for record submission, which is generally 45 calendar days from the date of the request. ADRs may arrive gradually over several weeks or in larger batches with the same submission deadline.

In the SNF setting, MACs frequently utilize prepayment review, which can significantly affect cash flow because claims, including subsequent claims for the same beneficiary, remain unpaid until the medical review is completed.

During each round, the MAC reviews a sample of approximately 20 to 40 claims submitted by the provider. Reviewers evaluate whether the claims meet Medicare requirements, including proper documentation, correct coding, and medical necessity for services provided.

After the review is complete, the provider receives a detailed results letter that identifies any errors and explains the reasons for claim adjustment or denial and is invited to schedule a one-on-one education session with a MAC educator. Education focuses on specific problem areas, such as missing documentation or incorrect billing practices. Once the education is complete, the next round of ADRs can begin at any time, starting 45 days after the education session.

Providers that demonstrate significant improvement and achieve an acceptable error rate may be released from the TPE process before completing all three rounds. If not, they move on to the next round of review.

Four Key Points

A few important points to keep in mind:

1. The MAC educator is not the same individual who reviewed the medical records and does not have access to individual claims or records.

2. Each MAC sets its own claim error rate threshold, which is not required to be publicly disclosed; however, they will notify you of the threshold during the education call.   Claim error rate thresholds can vary by jurisdiction.

3. The medical record must be complete and well-organized for submission to the MAC. There is generally little or no opportunity to provide additional information once the record is submitted for review.

4. Claim denials may be appealed through the Medicare Appeals Process; however, a successful appeal does not reduce or eliminate the error rate used for TPE purposes.

Third Round of TPE Review?

Most providers improve through the education process and are released from TPE before reaching the third round. However, providers that continue to demonstrate significant error rates after three rounds of review may be referred to CMS for next steps.

Potential actions include placement on a 100 percent prepayment review, extrapolation of identified overpayments, or referral to other Medicare audit programs, such as the Recovery Audit Contractor (RAC) or Unified Program Integrity Contractor (UPIC). These additional reviews are often more intensive and can result in increased administrative burden and financial exposure.

Positioning Your Facility for Success

Preparing for any audit begins long before an ADR arrives. Regular monitoring of skilled documentation, ongoing staff education, internal auditing, a comprehensive audit response plan, and analysis of denial trends can help facilities identify and address risk areas before they attract CMS attention.

As today's regulatory environment becomes increasingly complex, proactive compliance efforts remain one of the most effective ways to protect both reimbursement and program integrity.

Alicia Cantinieri, MBA, BSN, RN, CHC, RAC-MT, RAC-CTA, DNS-CT, QCP, managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group.

Questions or comments? Contact Patrick Connole at pconnole@parkplacelive.com.