Targeted Probe and Educate (TPE) Pilot
Beginning July 3, 2017, CMS has authorized Jurisdiction D to conduct the TPE Pilot review process. TPE will include up to three rounds of supplier-specific prepayment probe review followed by education to improve identified errors. The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education.
If a high error rate persists following the maximum rounds of review and education, Noridian will refer the supplier to CMS for possible further action. In addition, discontinuation of TPE may occur at the conclusion of any round if sufficient improvement is achieved through claim review.
Jurisdiction D suppliers can expect the following:
- Noridian will utilize existing data analysis processes to determine the item(s) and suppliers to review through TPE. Reference: CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2 .2
- Jurisdiction D suppliers identified for TPE will receive written notification from Noridian that will include the topic being reviewed, data reasons for the selection and the process of the review. The first-round prepayment probe review will begin following notification to the supplier.
- Suppliers with a high error rate on their prepayment probe review will receive an offer for one-on-one education relative to the specific errors identified through the probe review.
- Following education, suppliers are expected to make necessary adjustments/process changes with sufficient improvement demonstrated through claim review during the second-round probe review.
- If improvement in the second-round probe review is not sufficient, suppliers will undergo another round of education followed by another probe review.
- Following 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.
- Once a supplier has reached an acceptable error rate, the TPE process will end and Noridian will notify the supplier of successful completion.
If selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other pilot review programs, prior authorization, etc. as directed by CMS or other contractor reviews. Additionally, Noridian will continue to work with other CMS contractors and collaborate with referrals back and forth to the ZPIC/UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to ensure there is no duplication of reviews.
Last Updated Jun 27, 2017