The Centers for Medicare and Medicaid (CMS) has designed the Targeted Probe and Educate (TPE) program to help providers and suppliers reduce claim denials and appeals by providing one-on-one help. The CMS resumed TPE audits in September 2021 after suspending the TPE program during the earlier stages of the COVID-19 pandemic. For healthcare providers targeted in these audits, knowing what to expect—and how to prepare effectively—can be critical for avoiding unnecessary consequences. While TPE audits are not enforcement mechanisms as such, providers that are found in non-compliance during the TPE audit process can face follow-up enforcement action, and this can potentially lead to recoupments, prepayment review, and other consequences.
As a result, Medicare-participating healthcare providers that are facing TPE audits need to handle their situations carefully. Providers cannot assume that TPE audits are trivial or inconsequential. While they might be for providers that have a strong compliance record and the documentation to prove it, they can also be dangerous if not handled effectively.
“Facing a Medicare TPE audit isn’t necessarily as straightforward as it may seem. While these audits ostensibly focus on education and correction, issues uncovered during TPE audits have the potential to lead to CMS enforcement action if targeted providers do not address them effectively.” – Dr. Nick Oberheiden, Founding Attorney of Oberheiden P.C.
So, what do healthcare providers need to know about Medicare TPE audits in 2022? Here are some of the highlights:
1. The Focus of a Medicare TPE Audit is “Improvement”
According to CMS, the goal of a TPE audit is to help the targeted provider “quickly improve.” This refers specifically to improving the targeted provider’s billing compliance rate. Billing fraud costs CMS tens of billions of dollars annually; and, while some cases of billing fraud are intentional, many involve inadvertent mistakes that result from failure to adopt an effective Medicare billing compliance program.
2. Medicare Administrative Contractors (MACs) Conduct TPE Audits for CMS
As CMS further explains, during a TPE audit, “Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple . . . and are easily corrected.” Medicare Administrative Contractors are private companies that work with CMS to uncover billing violations. They have access to providers’ billings submitted to Medicare, and they have the authority to obtain and review providers’ billing records on CMS’s behalf.
TPE audits are intended to help providers address easily correctable errors that are not indicative of intentional Medicare fraud. Education is a key aspect of the process—in contrast to non-TPE Medicare Administrative Contractor (MAC) audits during which providers will often struggle to understand why they are being penalized. When conducting TPE audits, MACs are supposed to work collaboratively with providers to either (i) confirm that the providers’ billing practices are compliant, or (ii) identify and implement specific…