Streamlined audit and fraud program

In this second of our three-part series on the Center for Medicare and Medicaid Services’ (CMS) audit and fraud programs, the Advocacy Council (AC) focuses on the new “Targeted Probe and Educate” (TPE) initiative that the agency is launching this fall. This is a new approach to dealing with Medicare overpayments and replaces practices by Medicare Administrative Contractors (MACs) that many consider burdensome, if not abusive. Under the old system, a MAC could place a physician or other provider (including allergists) on pre-payment review for an indefinite period, even years, with no explanation. To be paid, providers were required to submit copies of patient records with every claim; there was no way to correct or appeal the situation.  

Under the new TPE initiative, the MAC selects a physician or other provider for targeted review based on data analysis. Physicians who are outliers in relation to their peers, are more likely to be targeted. The MAC will select 20-40 claims for prepayment review and, at the end of the period, will give the physician a detailed accounting of the results. At this point, the physician is offered a phone call with MAC staff, including a clinician and the individual that conducted the review. During the call, the physician can ask questions and receive an explanation of problem areas.

The MAC then gives the physician time to implement changes and corrections to their procedures in response to the audit results. This period of improvement will last at least 45 days and up to eight weeks - followed by another round of auditing - during which another 20-40 claims are subject to prepayment review. If problems persist, another educational intervention can be offered followed by another round of auditing. After three auditing rounds, if the problem is not corrected, it is referred to CMS for additional action which may include more prepayment review, referral to the Recovery Audit Contractor or other fraud programs.

If the physician disagrees with the audit results, they would still have access to the existing administrative appeals process. TPE has already begun in three MAC jurisdictions and is being rolled-out in other MAC areas in the upcoming months.

Advocacy Issue: 
Billing, Coding & Payments