Targeted Probe and Educate
In 2017, CMS implemented the “Targeted Probe and Educate Program” to “reduce claim denials and appeals through one-on-one help.”
Using data analysis, the Medicare Administrative Contractors (MACs) identify “providers and suppliers who have high claim error rate or unusual billing practices” and “items and services that have high national error rate and are a financial risk to Medicare.”
Common errors are (but not limited to):
- Certifying physician signatures missing
- Encounter notes not supporting all elements of eligibility
- Documentation not supporting medical necessity
- Missing or incomplete initial certifications or recertifications
First, if a practice or provider is identified by the MAC, a letter will be sent out. The MAC will then review 20-40 claims and accompanying medical records.
If the provider/practice is compliant…
The provider will not be subject to review again for at least one more year on the same topic.
If the claims are denied…
The provider will be invited to a one-on-one education session. The provider is given at least 45 days to make changes and improve. The claims will then be re-reviewed by the MAC.
If the provider has not improved in three rounds of education, they will be referred to CMS for next steps. The next steps may include a 100% pre-pay review, extrapolation, referral to a recovery auditor, or another action.
For More Information
Additional resources on the Targeted Probe and Educate Program can be found on the CMS website.