The U.S Centers for Medicare and Medicaid Services (CMS) published updated targeted probe and educate (TPE) information contained in Chapter 3 of the CMS Program Integrity Manual (Publication 100-08) through Transmittal No. 10132/Change Request (CR) 11695.
The transmittal can be downloaded here. It incorporates information about TPE practices providers have experienced but were not clearly outlined in the Manual.
It should be noted, however, that due to the current public health emergency, TPE reviews are currently suspended, though they are expected to resume after the emergency.
According to CMS’s updates, the TPE process is typically repeated for up to three rounds, but it may involve additional rounds at CMS direction. Also, CMS explains that another round of TPE will be conducted or the provider will be referred to CMS for further action if either the claim error rate or payment error rate is above the acceptable level.
Results of appealed denials (to the extent known at the time of referral) will be included; therefore, the sooner the provider can submit appeals, the better.
For providers who will be released from review due to meeting the established error rate goal, results letters shall indicate that the provider is being released from review for one year. One caveat, however, is that additional review may occur at any time should the Medicare Administrative Contractor (MAC) identify changes in billing patterns.
For providers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that the provider has not met the established goal error rate and will be referred to CMS for additional action, which may include: additional rounds of TPE review; 100 percent prepayment review; extrapolation; referral to a Recovery Auditor; and/or referral for revocation.