• providers and suppliers who have high claim error rates or unusual Billing practices, and
• items and services that have high national error rates and are a financial risk to Medicare.

TPE Audit Process

• If chosen for the program, providers will receive a letter from Medicare Administrative Contractor (MAC).
• The MAC will review 20-40 of your claims and supporting medical records.
• If compliant, providers will not be reviewed again for at least 1 year on the selected topics. MACs may conduct an additional review if significant changes in provider billing are detected
• If some claims are denied, providers are invited to the one-on-one education session. 
• Providers will be given at least a 45-days period to make changes and improve.

The majority of providers that have participated in the TPE process increased the accuracy of their claims. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for the next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.

Common Reasons for Claim Denials

CMS also mentioned 4 common reasons for claim denials:

1. The signature of the certifying physician was not included
2. Documentation does not meet medical necessity
3. Encounter notes did not support all elements of eligibility
4. Missing or incomplete initial certifications or recertification

Avoiding Medicare TPE Audits

Avoiding a TPE audit failure is essential for healthcare providers, no matter how rarely it happens. The best way to make the TPE audit process go smoothly is to have a compliance system in place and follow it to the letter. Regular training sessions with your billing team can ensure that they know and follow the billing guidelines. This can keep Medicare billing errors to a minimum and help providers pass TPE audits in as few rounds as possible.

Another way to avoid Medicare TPE audits is outsourcing your medical billing functions to an experienced medical billing company like us. MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. We can assist you in receiving accurate Medicare reimbursement for delivered services. To know more about our billing services, contact us at [email protected] / 888-357-3226

Reference: Targeted Probe and Educate