Targeted Probe & Educate
CMS has authorized Noridian to conduct the Targeted Probe and Educate (TPE) Pilot review process. This is a required process for providers targeted by Medical Review. The TPE review process includes three rounds of a prepayment probe review with education. If there are continued high denials after the first three rounds, Noridian will refer the provider and results to CMS. CMS will determine additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC/UPIC), referral to Recovery Auditor (RA) contractor, etc.
Note: Discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.
The key elements of this pilot include:
- Provider reviews will consist of three rounds of a prepayment Targeted Probe & Educate process. Noridian will select the topics for review and providers based on existing data analysis procedures outlined in 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, data reasons for selection, and process of review.
- Noridian may refer providers/suppliers to RA contractor or ZPIC/UPIC if providers do not respond to ADR requests and submit Noridian requested documentation.
- If warranted, education will be offered to the provider throughout the TPE process. Additionally, at the end of each "round," Noridian will provide notification in writing of findings of claim results and education on potential errors identified. Providers with high error rates will receive an offer for one-on-one education related to the specific errors identified. The goal for providers is to learn from education and improve their results in the next "round" to a low error category.
- Providers will be moved to another review "round" if error rates remain at a high level.
- Once a provider has reached an acceptable rate, the provider will be removed from review of that service and Noridian will continue to monitor data on that service/provider.
- Providers with continued high denial rate after three rounds of prepayment Probe and Educate reviews will be referred to CMS for possible further action.
If selected for this review, providers are not excluded from other Medical Review activities, such as, automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies, 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 Quality Integrity Organization (QIO) for concern of quality care, ZPIC for concerns related potential fraud/abuse, and RA for collaboration of vulnerability and ensure there is no duplication of reviews.
Last Updated Apr 23, 2018