Improved probe and education program targets specific providers within a particular service

Targeted Probe and Education (TPE) is an improved medical review strategy that will focus on specific providers/suppliers within the service rather than all providers and suppliers billing a particular service, according to a CMS news release. The TPE program began as a pilot in one Medicare Administrative Contractor (MAC) jurisdiction in June 2016 and was expanded in July 2017 to three additional MAC jurisdictions. Based on the success of the pilot programs, CMS plans to expand the TPE program to all MAC jurisdictions in 2017.

Probe and Educate program

The updated medical review strategy arose from an initial medical review strategy known as Probe and Educate, which combined the review of a sample of claims with education to help reduce errors in the claims submission process, but moves from a broader review to a more targeted one. TPE claim selection differs from previous probe and education programs because the TPE claims selection is provider/supplier specific from the outset rather than a review of all providers for a specific service; thus, eliminating providers who are submitting claims that are compliant with Medicare policy from the review process.

Under the Probe and Educate program, MACs focused on review of inpatient hospital admissions related to the two midnight rule and home health eligibility requirements. MACs reviewed selected claims submitted by acute care inpatient hospital facilities, long term care hospitals, and inpatient psychiatric facilities for admissions that occur between October 1, 2013 and March 31, 2014 (see CMS issues additional guidance for “two midnight” rule for inpatient hospital admissions, Health Law Daily, November 5, 2013). MACs continued to conduct “probe and educate” reviews for inpatient stays shorter than two midnights. Under the probe and educate process outlined in an earlier CMS release, MACs reviewed claims to determine if the inpatient stay of less than two midnights was reasonable and necessary (see CMS extends RAC prohibition of reviews of stays longer than 2 midnights, Health Law Daily, February 3, 2014).

The first round of the Probe & Educate program, MACs reviewed home health agency claims to assess compliance with and to promote provider understanding of Medicare home health eligibility requirements, (see HHA claims will be reviewed to confirm understanding of eligibility requirements, Health Law Daily, November 10, 2015). In round two of the program, MACs began a one-year period of claim reviews and provider education and will start submitting additional documentation requests (ADRs) on or after December 15, 2016 (see ‘Probe and Educate’ program for home health eligibility continues, Health Law Daily, December 20, 2016).

TPE process

Based on data analysis, Medicare Administrative Contractors (MACs) will review claims (1) for items and services that pose the greatest financial risk to the Medicare Trust Fund or have a high national error rate and (2) of providers/suppliers that have the highest claim error rates or billing practices that vary significantly from their peers. Under the TPE, MACs will review the 20 to 40 claims per provider/supplier, per item or service, and per round, for a total of three rounds of review. After each round of review, the MAC will offer the provider individualized, one-on-one education to address errors within the provider’s/supplier’s claims based on the results of the review.

Removal from the review process

Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates. However, providers/suppliers with moderate and high error rates in the first round of reviews will continue on to a second round of reviews, followed by additional provider specific education and those providers/suppliers that continue to have high error rates in the second round of review and education will continue to the third round. Providers/suppliers that continue to have high error rates after three rounds of TJPE may be referred to CMS for additional action.