New CMS Auditing Initiative

December 7, 2017

In addition to the proposed resumption of Recovery Audit Contractor (RAC) reviews mentioned in a previous news article, Medicare Administrative Contractors (MACS) will also begin conducting audits for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. 

Targeted Probe and Educate (TPE) is a new initiative for MACs to:

• Limit the number of medical records requested for review
• Emphasize education and assistance in correcting claims errors.

TPE was begun as a pilot program with one MAC in 3016 and is being expanded to all MACs in late 2017.  It involves the review of 20 to 40 claims per provider/supplier, per item or service, followed by personalized education.  MACs repeat this process of review and education up to three times.

The MACs will select which providers to review by identifying those practices having the highest claim error rates or billing practices that vary significantly from their peers. 

Providers who follow Medicare’s rules before the end of the three rounds will be removed from review for that topic.  Providers who do not will be referred to CMS for stronger corrective action. This new process has the potential to reduce the burden of complying with claims audits if you quickly become compliant with Medicare rules.

Find out more on the CMS TPE webpage at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html.