CMS Announces New, More Targeted Medicare Audit Process

The Centers for Medicare and Medicaid (CMS) had initiated a pilot program called Targeted Probe and Educate (TPE) where the Medicare Administrative Contractors focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. After each round, providers are offered individualized education based on the results of their reviews.

Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS. 

CMS is expanding the pilot TPE program to all Medicare Administrative Contractors. The purpose of this expansion is to reduce appeals, decrease provider burden, and improve the medical review/education process.

The Medicare Administrative Contractor (MAC) and not CMS will select the topics for review based on