REIMBURSEMENT PAGE
By JOSEPH MCTERNAN
The Return of TPE What to expect from the reinstated Target, Probe, and Educate program
TARGET
TPE PROGRAM PROBE
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 15 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
E! QU IZ M EARN
2
BUSINESS CE
CREDITS P.15
14
OCTOBER 2021 | O&P ALMANAC
C
MS ANNOUNCED A MAJOR shift
in audit strategy in August 2017: the Target, Probe, and Educate (TPE) program. TPE replaced traditional Medicare audit procedures that relied on expansive postpayment reviews, which subjected entire product categories across all providers to significant audit activity. The TPE program was very well received as it significantly reduced the overall number of Medicare audits, shifted much of the Medicare audit activity to prepayment audits, and provided increased education and communication between the provider community and the durable medical equipment Medicare administrative contractors (DME MACs). When the COVID-19 pandemic created unprecedented and unexpected shifts in the operation of the Medicare program, CMS initially suspended most audit processes. CMS announced in August 2020 that while Medicare contractors would once again be authorized to perform claim audits, all audits would be performed on a postpayment basis using the previous process of probe review followed by widespread postpayment review. The TPE program was temporarily suspended, and more comprehensive audit processes were put back in place. Today, the COVID-19 public health emergency (PHE) remains in place,
EDUCATION
but Medicare contractors are slowly returning to some sense of normalcy in how they process Medicare claims. CMS has authorized the contractors to reinstate many of the processes that were temporarily suspended due to the PHE. In August 2021, CMS announced that the TPE program would be reinitiated and would, once again, replace the widespread postpayment review process.
How Is TPE Different From Widespread Review?
The primary difference between the traditional probe review followed by widespread review model and the TPE program is that the TPE program is much more focused—not only in identifying a much smaller pool of claims for review, but also in providing education for providers who do not pass the audit process to improve their compliance with Medicare policy requirements and regulations. The TPE program consists of three rounds of prepayment review. Each round involves 20-40 claims that have been identified for review through detailed statistical analysis, which identifies specific areas of risk for the DME MAC contract area. Additional documentation requests are sent for each of these claims, and a standard prepayment review is performed. If the results of the first round of
