Targeted Probe & Educate (TPE) Audits

PUBLISHED: September 28, 2021

Resuming The Targeted Probe & Educate (TPE) Program

Last month, the Centers for Medicare & Medicaid Services (CMS) reported the Targeted Probe & Educate (TPE) program resumed after being suspended in March 2020 due to the COVID-19 public health emergency (PHE). Palmetto GBA and CGA released the TPE program resumed on September 1, 2021.

The National Association for Home Care & Hospice (NAHC) is advocating CMS to continue the TPE suspension until the PHE ends.

What is a Targeted Probe & Educate (TPE) Audit?

A target probe audit is an unannounced audit that is conducted to determine if a company’s processes and procedures are adequate enough to achieve compliance with specific regulatory requirements.

What happens in a TPE Audit?

Each Medicare Administrative Contractor (MAC) studies the claim data submitted by each provider to determine providers who have a 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 the TPE program.

Common Targeted Probe & Educate (TPE) claim errors include:

The signature of the certifying provider was not included
Face-to-Face (F2F) encounter notes did not support all elements of eligibility
Documentation does not meet medical necessity
Missing or incomplete initial certifications or recertifications

How the Targeted Probe and Educate Process Works

What to expect from the TPE Audit

Once selected, the agency will receive a letter from the MAC to let them know the agency has been chosen for round one. Whoever 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 has 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 calendar 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 the mail or technical issues. The 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 may take up to 60 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?

Responding to a TPE Audit

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). It is recommended a point of contact is included with the ADR response in the event the MAC contacts the provider by phone for easily curable errors. Include the requested documentation which is typical:

*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. Be sure to carefully divide each set of claim documentation when you are submitting multiple claims.

One on One Education

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.

Second Round

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 the goal of showing that you have made improvements and are below the 15% financial risk.

Third Round

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?

Passing the TPE Program

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 an additional review if significant changes in provider billing practices are detected.

Failing the Targeted Probe & Educate Audit

If you failed round three, your agency will be referred to CMS for the 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 ADR compliance services which will assist your agency with ADRs and Targeted Probe and Education (TPE) Audit Program.

McBee’s Solutions:

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, the 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 on forms, processes, and documentation.