What Your Agency Needs to Know About Targeted Probe & Educate
You are here: Home \ Blog \ What Your Agency Needs to Know About Targeted Probe & Educate

WELCOME TO MCBEE

APPROACH

MARKETS

SERVICES

INSIGHTS

  Blog

  Videos

  Webinars

  Infographics

COMPANY

   Team

   Case Studies

   News

   Careers

29 November 2018 - 13:35, by , in Blog, Compliance, Comments off

Last month, Centers for Medicare & Medicaid Services (CMS), began the Targeted Probe and Educate (TPE) program to help providers reduce claim denials and appeals through one-on-one education.  Each Medicare Administrative Contractor (MAC), studies the claim data submitted by each provider to determine providers who have high potential for claim error rates or unusual billing practices.  In addition, the MACs are also identifying trends for services that impose a high financial risk to Medicare.  If an agency has had high denials from Additional Documentation Requests (ADRs) in the past, they are at a high risk of being selected for of the TPE program.

How the Targeted Probe and Educate Process Works

targeted probe and educate

What to Expect

Once selected, the agency will receive a letter from the MAC to let them know the agency has been chosen for round one. Whomever is billing for the agency or on behalf of the agency will begin seeing the ADR claims labeled in status “S B6001” in the Medicare Financial Intermediary Standard System (FISS).  They may appear in groupings or all at once, but they will total either 20 or 40 claims.  Most likely there will be 40 claims.  If an agency is receiving ADRs but have not received a TPE letter, the agency should call the MAC immediately and ask them if they are under the TPE program.

The agency has 45 days to respond to an ADR; however, it is recommended that the agency targets their response to 30 days to allow for any delays in mail or technical issues.  Preferred method is through electronic submission, but an agency should confirm that all the documents are loaded and visible, and that confirmation of acceptance has been received when choosing this method.

When the agency’s information is received, the FISS will change the status to “SM50MR”. The MAC then has 30 days to review the response and make a payment determination. The agency should closely monitor FISS for any changes in claim status. These changes will be labeled as “Paid in full” (P B9997), “Denied” (D P9997), or “Partial Payments” (P B9997).

Once a determination has been made on all the claims, the agency’s financial risk is assessed by the MAC.  If this assessment is determined to be 15% or greater, the agency will receive a letter from the MAC inviting them to a one-on-one education session to review the greatest areas of need.

 

What Should Your Agency Do?

RESPOND – Prepare a response for all ADRs received even if you think the claim will be denied.  If you do not respond, then the financial risk amount will include the total amount for the non-response claim(s). Include the requested documentation which is typically:

Targeted Probe and Educate (TPE) ADR Checklist*source: https://www.cgsmedicare.com/hhh/medreview/adr_process.html

It is not necessary to include a cover letter with your response. However, the MAC may find it useful in finding key data.  Do use brackets “{ }” or “[ ]”, asterisks “*”, or underlined text in the documentation to draw the reviewer’s attention.  You can use divider pages to also separate key documents.

EDUCATE – If your claim denials are 15% or greater, you will need to schedule and attend the one-on-one education session.  Plan on attending and come prepared to ask questions regarding any areas of concern.  From the date of the education you will be given 45 days to improve.

ROUND TWO – Another 20-40 claims will be selected and placed in the ADR Status “S B6001”.  This will happen 45 days from your education and will impact ALL claims submitted to FISS from that date forward, regardless of the date of service.  Make sure that your compliance team and billing team are on the same page with these dates.  You will have to respond to all ADRs in round two with a goal of showing that you have made improvement and are below the 15% financial risk.

ROUND THREE – If you fail Round Two, you will repeat the same process as Round Two.  Attend the training and be mindful of the dates and claims submitted thereafter.

 

What to Expect After TPE

PASS:  If you passed any of the rounds and are compliant, your agency will not be reviewed again for at least one year on the selected topic. However, the MACs may conduct additional review if significant changes in provider billing practices are detected.

FAIL:  If you failed round three, your agency will be referred to CMS for next steps.  They may include:

  • 100% Pre-Pay Review
  • Extrapolation of the % Denied and Payback
  • Referral to a Recovery Auditor (ZPIC, UPIC, etc.)
  • Other actions as required

 

The McBee Solution for Targeted Probe and Educate

How can McBee help?  McBee has designed specific solutions which will assist your agency with ADRs and Targeted Probe and Education.  These solutions include:

  • ADR and Appeals Preparation
    • Gather and review all components of the patient’s record prior to submission.
  • Staff Education
    • Educate staff on clinical documentation requirements to reduce risk and properly document the patient’s condition.
  • Clinical Chart Review
    • In-depth review of the clinical documentation and billing compliance to assess your agency’s financial risk post-claim submission.
  • Pre-Bill Review
    • Prior to submission of claims to Medicare, McBee Clinical Compliance team will review the clinical and billing documentation for compliance risk and provide your agency with a risk scorecard. McBee’s clinical experts will review your documentation and make suggestions to forms, processes, and documentation.

 

 

**More on Targeted Probe & Educate…

Watch Video: Why Compliance Matters: Preparing for Probe & Educate

Blog Post: Targeted Probe & Education Continuation

 

About author: