CMS Releases Targeted Probe and Educate Medical Review Strategy

Recently, the Center for Medicare and Medicaid Services developed a new strategy entitled Targeted Probe and Educate (TPE) to tackle the issue of backlogged appealed and denied claims. The audit strategy intends to properly and efficiently review outstanding claims and issue reimbursements when appropriate, and is expected to launch within the next few months.

On December 5, 2016, the U.S. District Court for the District of Columbia granted a motion in regards to American Hospital Association (AHA) vs Secretary of Health and Human Services (HHS). The decision made by the District Court states that HHS must clear its backlog of appeals and denials of Medicare claims within four years.

In the case, that had been initially filed two and a half years earlier, the AHA, frustrated by the length of time taken to review Medicare appeal claims, filed suit and submitted several proposals as a part of the suit. The proposals, to which the District Court favored, provided a timetable for the current backlog of pending cases to be reduced by certain percentages over the next 4 years. The timetable is as follows:

• 30% reduction from the current backlog by December 31, 2017.
• 60% reduction from the current backlog by December 31, 2018.
• 90% reduction from the current backlog by December 31, 2019.
• Elimination of the backlog of pending cases at the Administrative Law Judge (ALJ) level by December 31, 2020.

Following the decision by the District Court, HHS filed an appeal with the Circuit Court, asking the judge to reconsider the initial decision of the case. In a Center for Medicare and Medicaid Services (CMS) report for 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 650,000 pending appeals, with an average adjudication capacity of approximately 92,000 appeals per year. The Secretary of HHS illustrated that for the amount of outstanding claims to be handled in such a short period of time would result in mass reimbursements to be released without proper verification of the claims themselves.

As a part of their appeal, HHS came up with a ‘three-prong’ solution addressing the increasing number of appeals as well as the backlog of current appeals waiting for adjudication from OMHA. 1) A request for new resources to invest in the current adjudication programs, 2) Administrative action to reduce the number of appeals, reducing some of the backlog, and 3) Propose legislative reforms that provide additional funding for the volume of appeals issues.

The Circuit Court agreed and reversed the initial decision of the District Court in August of 2017, based on the fact that the Secretary of HHS showed that compliance with the four year timetable initially provided by AHA was impossible. The Circuit Court also claimed that the District Court did not properly evaluate the HHS’ belief that the four year timetable would increase the number of backlogged appeals.

In an effort for HHS to begin to clear up the outstanding claims backlog, CMS, the division of HHS who oversees the Medicare program, introduced the TPE strategy. Based on a pilot program from 2014, the new program will have Medicare Administrative Contractors (MAC’s) focus primarily on claims that have more financial impact to the overall Medicare trust fund. MAC’s will also focus on providers who have the highest claim error rates or billing practices that greatly vary from other providers.

The new TPE review process will entail reviewing 20-40 claims with one-on-one follow ups and continuing education to address ongoing provider issues. Providers with continued high error rates will be moved on to second, third and fourth level probes. After the third level, providers with continued high error rates may be referred to CMS for continued actions, including prepay review, extrapolation, referral to a Recovery Auditor, or other actions.

The main goal of the strategy is to reward providers for accurate, error free billing, and offer support and continuing education for those providers who need it. In essence, the better billing system your facility utilizes, the fewer errors will be made, and the less likely CMS will tend to audit you. Marcum, LLP has experienced Medicare billing representatives who are able to answer any questions you may have regarding TPE or how to optimize your Medicare billing practices.