August 25, 2017
Facilities with high claim error rates will be selected for review by surveyors in 2018
After reporting favorable results from a pilot program started in 2014 to reduce errors in the Medicare claims submission process, CMS announced last week that they will move forward with the new auditing strategy—which combines a review of a sample of claims with education—changing the process slightly by moving from a broad “Probe and Educate” program to a more targeted strategy, referred to as Targeted Probe and Educate (TPE).
How are claims selected for TPE?
MACs will select claims for items/services that pose the greatest financial risk to the Medicare trust fund, and/or those that have a high national error rate. In other words, says CMS on their TPE webpage, “MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers. These providers/suppliers and specific items/services are identified by the MAC through data analysis.”
This auditing process is different from the previous strategy because, “whereas previously the first round of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset.” CMS believes this will “eliminate burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.”
How does the process work if your facility’s claims are selected?
The TPE review and education process includes a review of 20-40 claims followed by one-on-one, provider-specific, education to address any errors with in the provider’s reviewed claims. Providers/suppliers with moderate and high error rates in the first round of reviews will continue on to a second round of 20-40 reviews, followed by additional, provider specific, one-on-one education.
Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education. In addition to education at the conclusion of each 20-40 claim probe review, MACs will also educate providers throughout the audit process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process. A flow chart outlining this process can be viewed here.
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.
Reduce the fear of an impending audit and take a proactive approach to preparedness today!
Source: Health Leaders Media
http://www.healthleadersmedia.com/leadership/cms-announces-new-more-targeted-medicare-audit-process