Targeted, Probe and Educate - CMS' Audit Program for Providers - DoctorsManagement Targeted, Probe and Educate - CMS' Audit Program for Providers - DoctorsManagement

Targeted, Probe and Educate

“CMS’s Audit Program for Providers”

by Sean Weiss, Partner & VP of Compliance

What’s in a name? When it comes to Medicare, the answer is a lot. This program was created in 2017 and serves a significant purpose to the MACs. This program is used for conducting post-payment claims reviews. TPE started as a pilot but expanded to all MAC jurisdictions in 2017. I have found a lot of variations of how this process runs depending on the MAC. For example; with First Coast Service Options, the MAC in Florida, they have the program down pat and the nurses that conduct the education sessions are outstanding and truly working to educate the providers and staff within their practice. Novitas however, seems to send a letter and then, without providing education, demands another series of records, which defeats the purpose of the program because without education, the providers are bound to make the same mistakes over and over and potentially lead to a referral to CMS or OIG.

The actual methodology behind TPE is quite simple; below is a breakdown of all three (3) rounds and potential penalties for failing three (3) reviews.

The selection of claims is as follows:

  • Items/services that pose the greatest financial risk to the Medicare trust fund and/or have the highest error rates.
  • Focus on providers/suppliers identified through data analysis who have the highest claim error rates or have outlier billing practices.
  • Up to 3 rounds, where MACs will review 20-40 claims, per provider, per round.
  • Each round accompanied and followed by 1-on-1 education based on review results.
  • Providers with continued high error rates after 3 rounds may be referred to CMS for additional action.

You may be asking why Medicare has moved to a medical review strategy to use data to identify providers and the answer is simple: “To review (Targeted) providers either based on outlier status or aberrant coding patterns.” I have talked about options for internal use that mirror the efforts of CMS and commercial payers in the past. If you are not utilizing a data risk analyzer such as Compliance Risk Analyzer (CRA) you’re missing out on an opportunity to identify potential risks within your organization before an investigator does. For more information on CRA, click the following link:; you no longer have to operate in the blind!

With the TPE, the goal is to pull smaller samples of claims (Probe) and then provide direct feedback on the results of the probe (Educate). So, why is CMS moving to the TPE process for medical review? The answer is simple; the results of previous Probe and Educate (P&E) programs have been well received by the provider/supplier community in their opinion so why not expand the program further. Additionally, positive results of the TPE pilot program included a decrease in appeals as well as an increase in provider education which resulted in decreased denial rates for a vast majority of providers as they progressed through the P&E process.

These initial P&E programs, however, included all providers/suppliers that billed a particular service. In an effort to refine the P&E programs, CMS determined that efforts would be better directed toward those providers/suppliers who, based on data analysis, provide the most risk to the Medicare program, and not to all providers/suppliers billing a particular item/service. The process is again quite simple:

  • Providers are selected for review based on data analysis procedures used by the MAC
    • Up to three rounds of pre/post pay review will be performed
    • Sample size up to 40 claims for each round
  • One-on-one education will be performed after each round is completed
    • I have found with several of my clients that education is not being provided through the program as they are supposed to and ADRs are being sent notifying them of advancement to 2nd round. Know your rights and stop the automatic forwarding to additional rounds by contacting the reviewer on the initial letter provided to you to: inform them that going on to another round without education is not how the program was designed; and without education to correct the issues or provide an explanation your documentation will only result in the same mistakes being noted again. After phone calls to the auditor conducting the reviews, I have been successful with halting the next round until formal education is provided and our rebuttals have been made and taken into consideration or an appeal is filed.
  • Education may also be initiated during the probe process
    • The 20-40 claim sample size is intended to allow the MACs to review enough claims to be representative of how accurately providers/suppliers have the necessary supporting documentation to meet Medicare rules and requirements, while not being overly burdensome.
    • Goal is to gain compliance with the Medicare Policy Requirements within the three rounds
    • If acceptable improvement is not achieved, a referral will be made to CMS
  • Examples of additional action that may be considered (not an all-inclusive list):
    • Post pay w/extrapolation
    • Higher levels of prepay review
    • Referral to the ZPIC/UPIC
    • Referral to the Recovery Auditor

At the conclusion of each round of 20-40 reviews, providers/suppliers will be sent a letter detailing the results of the reviews and offered a 1-on-1 education session; accept it! The MACs will also educate providers/suppliers throughout the TPE review process when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process. As I stated before, CMS’ experience has shown that this education process is well received by providers/suppliers and helps to prevent future errors. During a one 1-on-1 education session (usually held via teleconference or webinar), the MAC provider outreach and education staff will walk through any errors in the provider/supplier’s 20-40 reviewed claims. Providers/suppliers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed. If selected for review, it does not exclude the provider from other MR activities, for example:

  • Automated reviews
  • Comparative billing reports
  • Mandated demand bill reviews
    • The error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review.
    • The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process.
    • The appeals process is unchanged under the TPE process. If a claim denial is appealed and overturned, this would be taken into consideration in subsequent TPE rounds.
      At the conclusion of each round of review, the MAC sends the provider/supplier a letter detailing the results of the 20-40 claims reviewed during that round, including details regarding claim errors. This letter may be sent before or after the final one-on-one educational call.

Make certain to establish a Provider Point of Contact (POC) – here are some simple recommendations:

  • Establish a POC for the MAC Case Manager to work with
  • Reach out to the MAC POC as needed
  • Review the Medicare Policy requirements for the service
    • The resources are included in the notification letter
  • Be engaged and participate throughout the review/education process
    • For webinar education offered, it is okay to include multiple people from your office

The education session in each round is developed based on the review findings from the most recently completed round of reviews and is not the same unless errors found in the reviewed claims are the same. The education will reinforce corrections that should be made for errors that continue to be identified in subsequent rounds. CMS is encouraging MACs to use all available sources of data when selecting providers to include in the TPE process. The results of previous P&E programs are one source of data that MACs will use to select providers for review. MACs will also use provider billing and utilization patterns as well as provider specific error rates. If a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review. Additionally, if a provider/supplier submits claims to Medicare for more than one item or service, each item/service could be subject to a separate probe as part of the TPE program. Providers/Suppliers and the specific items and services included in the TPE process are those who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers.

When you receive Additional Documentation Request (ADR) Letters make sure you do not sit on them for any period of time since the requirement to return medical records is typically within 45 days and the more charts requested (maximum 40), the more time and effort it will take to prepare them and get them sent. Some recommendations to follow:

  • Know who receives them/where they go
  • Know/Track when responses are due back to Noridian
  • Providers are allowed 45 days to respond
  • It’s better to respond with something versus nothing

Reminder for Lab Providers

  • MR will continue to reach out to ordering/referring providers when documentation submitted is not sufficient per CMS instruction (IOM100-08 Chapter 3, however, providers are encouraged to reach out during the ordering/referring to obtain necessary documentation to aid in the review process

Here us a link for you to follow regarding the process and how CMS is using Statistics and Data Mining to target providers.

CMS website

What to do next…

  1. If you need help with an audit appeal or regulatory compliance concern, contact us at (800) 635-4040 or via email at
  2. Read more about our: Total Compliance Solution

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