Targeted Probe and Educate (TPE) - JF Part A

Implementation

CMS has authorized Noridian to conduct the Targeted Probe and Educate (TPE) review process. This is a required process for providers targeted by Medical Review.

Overview

Includes up to three rounds of pre-payment probe review of 20-40 claims followed with education. Providers will be moved to a subsequent round if high errors are identified. If no errors or low errors, a subsequent round will not be initiated; however, Noridian will continue to monitor data.

If there are continued high errors after the first three rounds, Noridian will refer the provider to CMS. CMS will determine additional action, which may include extrapolation, referral to Recovery Audit Contractor (RAC), 100% pre-payment review, additional round of claim review, etc.

Process

• Noridian will select topics for review and providers based on existing data analysis procedures outlined CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
• Noridian will notify providers in writing on the topic being reviewed, reasons for selection, and process of review.
  • If selected for a TPE review, providers are not excluded from other Medical Review activities such as post-pay reviews by other CMS contractors.
  • Noridian MR will work with other CMS contractors and CMS programs to ensure there is no duplication of reviews within CMS directions.
• Noridian may refer providers, to RAC or UPIC, if providers do not respond to ADR request by submitting requested documentation.
• Education occurs, if warranted, throughout the TPE process and at the end of each round. Noridian provides written review findings with education on errors identified. Providers with errors will receive an offer for one-on-one education.

Goals

Learn from education and decrease errors.

Current Trends

Noridian provides widespread education related to top trending TPE medical review errors found. To review top trending errors and related education, visit Medical Record Review Results.

Resources

To watch a CMS video to learn more about TPE go to Targeted Probe and Educate.