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What can we expect with targeted probe-and-educate programs resuming?

The Centers for Medicare & Medicaid Services indicated in August 2021 that the TPE program would resume, ending a temporary suspension in place since March 2020 due to COVID-19. Some Medicare Administrative Contractors (MACs) had already indicated either active topics, or confirmation of beginning TPE activity, effective Sept. 1, 2021.

These MAC reviews target providers based on data analysis identifying them as high risk for overpayments, or with unusual billing practices compared to peers, and/or with high rates of denial. The Medicare Program says the purpose of TPE is to decrease provider burden, reduce appeals, and improve the medical review/education process.

TPE reviews can involve prepayment or postpayment claims. If selected, you’ll receive notification from your MAC outlining the topic being reviewed, reasons for selection and the review process. A single round of TPE typically involves the review of 20 to 40 claims. Besides a notification, an Additional Document Request (ADR) will be generated for each claim selected.

You’ll have 45 days from the date of the ADR to submit documentation. MACs then have 30 days from the date the documentation is received to review and make a payment determination. At the end of each probe round, review results will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part and associated education.

Depending on denial error rates, providers may be required to participate in up to three rounds, but the MAC may also continue through additional rounds at CMS’s direction. Provider claims that are denied in full or in part may be appealed through the normal Medicare appeals process.