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Targeted Probe and Educate (TPE)

Beginning July 3, 2017, CMS has authorized Jurisdiction D to conduct the TPE review process. TPE will include up to three rounds of supplier-specific prepayment probe review with a focus on one-on-one education throughout the process 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 three rounds of review and education, Noridian will refer the supplier to CMS for possible further action. In addition, discontinuation of TPE may occur after any round if sufficient improvement is achieved through claim review.

Jurisdiction D suppliers can expect the following:

  • Noridian will use existing data analysis processes to determine the item(s) and suppliers to review through TPE. 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.
  • Throughout each probe and after each round, suppliers will receive one-on-one education on the specific errors identified throughout the probe review(s).
  • Following education at the end of the round, suppliers are given six to eight weeks to allow for necessary adjustments or process changes to demonstrate sufficient improvement 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, 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 the supplier of successful completion.
  • 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.

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. Additionally, 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) if concerns related to potential fraud/abuse are identified at any point during the TPE review process.

Additional TPE information can be found on the CMS website.



Last Updated Jan 11, 2018