SHARE TPE FEEDBACK
Targeted Probe and Educate (TPE) Review Program
The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education. On August 12, 2021, CMS announced the restart of the TPE program (after it had been suspended in March 2020 due to the COVID-19 Public Health Emergency). Please note the following:
- Post-payment reviews that are already in process will be completed. Continue to respond to all Additional Documentation Requests, including those for post-payment reviews.
- All TPE cases that have remained open during the PHE are being closed.
- The TPE review process may include up to three rounds of a prepayment claim review with education.
- Suppliers selected for TPE will start at round 1, regardless of prior inclusion in the program.
TPE Process
TPE can include up to 3 rounds of supplier-specific prepayment probe reviews. During each round, CGS works with the supplier through education and 1x1 assistance to reduce billing errors and decrease the denial error rate.
- If there are no errors identified in the first set of initial 10 claims (in round 1), CGS will close the TPE case for that specific HCPCS code.
- If there are errors identified within the first set of 10 claims reviewed, the round 1 probe will continue.
- Upon completion of rounds 1, 2, or 3 probes, if suppliers show sufficient improvement during claim reviews, CGS may discontinue the TPE.
- If a high error rate persists after round 3, CGS will refer the supplier to CMS for possible further action.
How are the TPE suppliers chosen?
CGS will utilize existing data analysis processes to determine the item(s) and suppliers to review through TPE. Reference: CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.2
What can Jurisdiction B suppliers expect?
- Jurisdiction B suppliers identified for TPE will receive written notification from CGS that will include the topic being reviewed, data reasons for the selection and the process of the review. The first-round prepayment probe review will begin following notification to the supplier.
- We recommend signing up for DME myCGS to submit your responses directly within the portal. To get started, refer to the myCGS Registration and Account Management Guide.
- Suppliers with a high error rate on their prepayment probe review will receive an offer for one-on-one education relative to the specific errors identified through the probe review.
- Following education, suppliers are expected to make necessary adjustments/process changes with sufficient improvement demonstrated through claim review during the second-round probe review.
What if Error Rate Does Not Indicate Improvement?
- If improvement in the second-round probe review is not sufficient, suppliers will undergo another round of education followed by another probe review.
- Following three rounds of probe and education, suppliers that do not demonstrate sufficient improvement in their error rate will be referred to CMS for possible further action.
- Once a supplier has reached an acceptable error rate, the TPE process will end and CGS will notify the supplier of successful completion.
If selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other review programs, prior authorization, etc. as directed by CMS or other contractor reviews. Additionally, CGS will continue to work with other CMS contractors and collaborate with referrals back and forth to the UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to ensure there is no duplication of reviews.
Resources
- CMS TPE Information
- Resumption of the Targeted Probe and Educate (TPE) Medical Review (MR) Strategy - Revised
- TPE Flow Chart
- Process Improvement Plan (PIP)
Updated 02.28.23