The DME MACs have a new tool called the Targeted Probe and Educate.
Applicable to ALL Four Jurisdictions the program began last October 2017.
Targeted Probe and Educate will include up to three rounds of supplier-specific prepayment probe reviews followed by education to improve identified errors. The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education.
If a high error rate persists following the maximum of 3 rounds of review and education, CGS will refer the supplier to CMS for possible further action. In addition, discontinuation of TPE may occur at the conclusion of any round if sufficient improvement is achieved through claim review.
TPEs apply to all Medicare DMEPOS suppliers including post mastectomy providers.
According to the CGS Administrators (Jurisdiction C) website
Jurisdiction C suppliers can expect the following:
- CGS will utilize existing data analysis processes to determine the item(s) and suppliers to review through TPE.
- Jurisdiction C suppliers identified for TPE will receive written notification from CGS that will include the topic being reviewed, data reasons for the selection and the process of the review. The first-round prepayment probe review will begin following notification to the supplier.
- Additional Documentation Request (ADR) letters will be sent separately for the claims included in the probe (approximately 40 claims per each probe review).
- Suppliers with a high error rate on their prepayment probe review will receive an offer for one-on-one education relative to the specific errors identified through the probe review.
- Following education, suppliers are expected to make necessary adjustments/process changes with sufficient improvement demonstrated through claim review during the second-round probe review.
- If improvement in the second-round probe review is not sufficient, suppliers will undergo another round of education followed by another probe review.
- Following three rounds of probe and education, suppliers that do not demonstrate sufficient improvement in their error rate will be referred to CMS for possible further action.
- Once a supplier has reached an acceptable error rate, the TPE process will end and CGS will notify the supplier of successful completion. Suppliers will continue to be monitored through data analytics after successfully completing TPE and may have subsequent probe reviews conducted as needed.
If selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other pilot review programs, prior authorization, etc., as directed by CMS or other contractor reviews. Additionally, CGS will continue to work with other CMS contractors and collaborate with referrals back and forth to the ZPIC/UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to prevent duplication of reviews.