Here’s what you should know:
1. Targeted Probe and Educate pinpoints providers with high claim error rates or unusual billing practices for items and services with high national error rates. Most clinicians won’t ever be subject to a TPE review, but anesthesia-related services might come under scrutiny.
2. Through TPE, CMS reviews a representative sample of specific providers whose variance from their peers poses a financial risk to Medicare. The process is an alternative to reviewing all providers who bill a particular item or service.
3. The approach is intended to give audited practitioners a chance to fix deficiencies to avoid denied claims.
4. Providers selected for a probe will receive a letter from a Medicare Administrative Contractor, who will review 20 to 40 claims and supporting medical records. If some claims are denied, the provider will be invited to an education session and given at least 45 days to improve.
5. Medicare Administrative Contractors audit specific CPT and HCPCS codes with the highest potential for fraud, abuse or error.
6. Common claim errors include missing the certifying physician’s signature, encounter notes not supporting all elements of eligibility, insufficient documentation of medical necessity and missing or incomplete initial certifications or recertifications.
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