All the hard work you and your teams do can be negated by submitting claims that do not meet the medical billing guidelines set forth by CMS. Repeated mistakes in medical billing will impact the practice’s revenue collections. They may result in your medical practice being sent the notice for a TPE or Targeted Probe and Educate from CMS.
What is Targeted Probe and Educate or TPE?
Accurate Medicare claims benefit everyone, and CMS’s Targeted Probe and Educate (TPE) program aims to help providers submit claims correctly to reduce denials and appeals. Through personalized education, CMS-assigned Medicare Administrative Contractors (MACs) work with providers with high error rates, helping them identify and correct common issues.
The TPE process includes reviewing a sample of claims, offering educational sessions if errors arise, and allowing providers time to improve before further review. For most providers, this results in higher accuracy and compliance.
How Does the TPE Work?
If your medical practice is chosen for the TPE program, you will receive a letter from your Medicare Administrative Contractor or MAC. It will look something like this (image below):
A CMS-appointed MAC will visit your office to review 20-40 of the claims submitted by your medical practice and the supporting documentation provided along with the claims. The aim is to identify billing errors and anomalies.
The practice is then provided a one-on-one session for reasons of denied claims and given information on how to avoid these mistakes in the future.
Your practice will be given at least 45 days’ notice to change your billing processes and improve billing outcomes.
There are three categories of TPE review: Minor, Major, and Critical. The last two categories of reviews can have additional rounds or targeted probe education. However, those who continue to show issues after three training rounds may face additional CMS actions.
The Good News is TPE is Completely Avoidable
The good news is that TPE reviews are entirely avoidable because most claim denial reasons can be prevented by paying attention to the basics. The most common reasons for denials are:
- The certifying physician’s signature is missing.
- The documentation provided does not substantiate medical necessity.
- The encounter is not eligible for the claim.
- Missing initial certification.
- High dollar per patient payment over the jurisdiction average.
- Incorrect use of CPT codes
To avoid claims denials, ensure that your providers follow the AMA billing guidelines and are specific in reporting the CPT and ICD 10 codes. The following should be noted during the provider documentation process.
- Physicians should mention what specific tests they are ordering.
- Any medication changes should be included.
- Any treatment mentioned should be specific.
- Any discussions with outside providers of another specialty and the patient’s family members should be included.
Do you need more information on TPE notices or how to avoid receiving one for your medical practice? Please fill out our contact form at www.practiceforces.com to book a consultation now.
