Targeted Probe and Educate (TPE) is one process that a Medicare Administrative Contractor (MAC) can utilize when providers are selected 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 of reviews, Novitas will refer the provider and results to the Center for Medicare and Medicaid Services (CMS). CMS will determine additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the 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 probe and educate include:
Provider reviews will consist of three rounds of a prepayment TPE process. Novitas 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 This link takes you to an external website. .
Novitas will notify providers in writing of the topic being reviewed, the reasons for selection which will be supported by data analysis, and the process of review.
- Novitas may refer providers/suppliers to the RA contractor or to the ZPIC/UPIC if providers do not respond to additional documentation requests (ADR).
- Education will be offered to the provider throughout the TPE process. Additionally, at the end of each “round of reviews,” Novitas will provide notification in writing the results of the claim reviews and will provide education on the potential errors identified. Providers with a moderate or major error classification will receive an offer for one-on-one education related to the specific errors identified. The goal is for providers to learn from education and improve their claim review results in the next “round of reviews.” The goal is to achieve no errors or a minor error classification.
- Providers will be moved to another round of review if the error rate remains at a moderate or major error classification.
- Once a provider has reached a minor error classification, they will be removed from review of that service and Novitas will continue to monitor their claims data on a proactive, routine basis.
- Providers with a continued moderate or major error classification after three rounds of prepayment TPE reviews will be referred to CMS for possible further action.
- If selected for a TPE 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, Novitas will continue to work with other CMS contractors and collaborate with referrals back and forth to the Quality Integrity Organization (QIO) for quality of care concerns, the ZPIC/UPIC for concerns related to potential fraud and/or abuse, and the RA contractor to ensure there is no duplication of reviews.
All topics for review can be seen here.