Targeted Probe and Educate (TPE)
CMS authorized Jurisdiction A to conduct the TPE review process October 1, 2017. The goal of TPE is to improve a supplier's claim payment error rate and reduce the volume of appeals through claim review and education.
New in TPE
CMS has authorized DME MACs to conduct a 10-claim preview of Round 1 in addition to the normal TPE process. This preview is intended to reduce burden for compliant suppliers. If the Round 1 preview results in zero errors, no further action is required and the TPE review will be closed. Results will be communicated via telephone call or letter.
How Does It Work?
- Noridian uses existing data analysis to determine item(s) and suppliers to review through TPE
- TPE includes up to three rounds of supplier-specific prepayment probe review with a focus on one-on-one education throughout process to improve identified errors
- Identified suppliers receive written notification from Noridian that includes topic being reviewed, reason for selection and process of review. First-round prepayment probe review will begin following notification to supplier
What Happens During the Review?
- Throughout each probe and after each round, suppliers will receive one-on-one education on specific errors identified
- Following education at end of round, suppliers are given six to eight weeks to allow for necessary adjustments or process changes to demonstrate sufficient improvement through claim review during second-round probe review
- If improvement in second-round probe review is not sufficient, suppliers will undergo another round of education, a six to eight-week improvement period and a third probe review
- Once a supplier has reached an acceptable error rate, the TPE process will end and Noridian will notify supplier of successful completion. If sufficient improvement is achieved through claim review, discontinuation of TPE may occur after any round
What Happens if Error Rate Does Not Indicate Improvement?
- After 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 which may include 100% prepay review, extrapolation, referral to other review or fraud entities, etc.
If selected for TPE review, suppliers are not excluded from other MAC Medical Review activities, such as automated reviews, other pilot review programs, prior authorization, etc., as directed by CMS or reviews conducted by other CMS review contractors. If concerns related to potential fraud/abuse are identified at any point during the TPE review process, Noridian will continue to work with other CMS contractors, such as coordinating referrals to the Zone Program Integrity Contractor (ZPIC), Unified Program Integrity Contractor (UPIC) or Recovery Auditor Contractor (RAC).
Last Updated Jan 15, 2019