The Centers for Medicare and Medicaid Services have replaced the Progressive Correction Action or PCA with Targeted Probe & Educate or TPE. TPE is designed to give providers with the one-on-one assistance they need to reduce claim denials.
If a provider is chosen for TPE, they will receive a letter from the MAC. The MAC will review 20 to 40 of the provider's medical claims and supporting medical records. In the event a provider is compliant, they will not be reviewed again for at least a year on the selected topic.
If there is a denial of some claims, the provider will be invited to a one-on-one education session. The one-on-one education session will likely be held via webinar or teleconference and walk through any errors in the 20 to 40 of the provider's reviewed claims. Providers will also receive the chance to ask questions regarding their claims and CMS policies that apply to the services or items that were reviewed.
After the one-on-one education session, they will be granted a 45-day period to make changes and improve. After the 45-day period, the MAC will again review 20 to 40 medical claims and supporting medical records, and the process repeats.
Fortunately, the majority of providers that have participated in the TPE process have successfully increased their claim accuracy. However, if providers fail to improve after three education sessions, they will be referred to CMS for next steps, which may be 100 percent prepay review, extrapolation, or a referral to a Recovery Auditor.
It is important for healthcare professionals to treat TPE as seriously as they would treat any other governmental audit. The attorneys at Nicholson & Eastin, LLP encourage providers who receive TPE notification letters to reach out right away. We can help guide providers with responding and without disrupting the productivity and workflow of their practice.