New Version of TPE for Smaller Providers Is Coming To Reduce Burden

With the goal of reducing provider burden, CMS will test drive audits for providers and suppliers who are low-volume billers—a sort of Targeted Probe and Educate-lite.

“We designed a review strategy specific to smaller providers and suppliers,” Daniel Schwartz, director of the Division of Medical Review in the CMS Center for Program Integrity, said May 9 at CMS’s Provider Compliance Focus Group.

The starting date of the pilot program has not been decided. But Schwartz explained the differences between Targeted Probe and Educate (TPE), which is CMS’s main medical review strategy, and the low-biller probe-and-educate pilot:

  • While TPE is designed for providers and suppliers who bill at least 20 claims in a three-month period, low-biller probe-and-educate is intended for providers and suppliers who bill fewer than 20 claims in a three-month period.

  • TPE involves up to three rounds of review of 20 to 40 claims followed by one-on-one education, while low-biller probe and educate includes as many as three rounds of review of five claims followed by one-on-one education.

  • Medicare administrative contractors (MACs) have discretion to add TPE rounds of review, while CMS will decree what error rates in low-biller probe and educate will trigger additional rounds of review.

  • MACs permit 45 days after one-on-one education before starting subsequent rounds of TPE review. With low-biller probe and educate, MACs will permit three months before starting a subsequent review. The extra time will allow “providers and suppliers to absorb and use that education before the next round,” Schwartz said.

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