Targeted Probe and Educate (TPE) can be a zero-tolerance medical review strategy, which means a single claim denial could push providers from one round of audits to the next.

“There is no acceptable error rate,” said Christine Hall, president of Stirling Global Solutions, at a Feb. 27 webinar sponsored by the Health Care Compliance Association.

But if providers appeal claim denials between rounds, they may be able to bring the audit to a close. It happened for Inova, a health system in northern Virginia, said Compliance Manager Ashley Henderson. The catch: the Medicare administrative contractor (MAC) may not tell you the audit is over, because appeals and TPE are in separate departments. “That was a new experience, but not an easy experience,” she said. In the end, however, “it worked out well.” The importance of communicating with the MAC is one of the lessons of that interaction with TPE, which many providers say is preferable to other audits, partly because there’s generally not a tidal wave of audits, and because the MACs provide one-on-one education where they discuss specific errors with providers.

Henderson said Novitas, the MAC, audited claims for critical care services submitted by Inova physicians. “We were unsuccessful in round one and sent to round two,” she said. Because the physicians were emphatic about the accuracy of the claims, Henderson filed an appeal. “We had six or seven claims denied in round two, and we appealed four or five of them, and that got us off TPE,” she said. “But there was no explanation. We didn’t receive notice we were no longer under audit, so we were waiting around anxiously for round three.” Eventually, Henderson called the MAC to ask about its third TPE round, and that’s when she found out the audit had been dropped because of the successful appeal. “They never sent us a letter,” she said. It’s a reminder of how vigilant compliance officers and physician advisors must be with TPE.