Understanding TPE Audit in Healthcare: What Providers Need to Know

Targeted Probe and Educate (TPE) Program educates providers and medical practices to reduce billing errors. Similarly, it helps reduce the denial rate by reviewing the data based on analytics. TPE audit in healthcare identifies billing errors and calls the provider for multiple review rounds. A provider can hire medical billing audit services to reduce the likelihood of going through the TPE audits. By conducting internal audits, you can improve the claims submission process. In this blog, you’ll learn about the TPE program, its essential features, how it works, and ways to handle the MACs.

What is a TPE Audit in Healthcare?

TPE is an abbreviation for Targeted Probe and Educate Program. The Centers for Medicare & Medicaid Services (CMS) introduced it as a replacement for the Probe and Educate program in 2017. Medicare Administrative Contractors (MACs) conduct this medicare review program to identify the root cause of billing inefficiencies. TPE Audit in Healthcare focuses on specific providers with high denial rates. The objective is to identify billing errors and educate providers facing claim submission issues. Likewise, it helps providers sustain financial growth by educating them on improving the AR recovery process.

Common Reasons for TPE Audit in Healthcare

The following are some common reasons for TPE audits in healthcare.

The signature of the certifying provider is missing.
Supporting documentation is incomplete.
The denial rates are increasing in number.
Unusual billing patterns arise for a specific service.
Data analytics shows potential billing errors.

Essential Features of TPE Audit in Healthcare

Targeted Approach

TPE doesn’t target all the providers for review because it ensures a targeted approach. Likewise, the selection is based on the data analysis. This audit targets specific services, providers, and billing practices with a high risk of billing errors.

Probe Reviews

The MAC will ask for at least 20-40 claims and supporting documentation to review the billing errors. They analyze the billed services and supporting documents to detect why claim denial rates are increasing.

Education

After critically analyzing the probe reviews, the MAC provides education to the providers. They educate the selected providers on how to reduce the claim denial rates.

Three-Round Review Process

The selected providers have to undergo multiple review rounds as per the report from the TPE audit in Healthcare.

Round 1: The provider gets counseling on unusual billing patterns in the first round. Furthermore, the physician is asked to review the claims as per instructions.
Round 2: If errors remain, the provider receives additional education and undergoes a third review.
Round 3: If the errors persist after two rounds, the provider is referred to another Medicare Review Program.

Possible Outcomes

When the provider is successful with the clean claims, the MAC stops the review program. Conversely, if the errors continue, the provider faces further action, such as a prepayment review or suspension of Medicare payments. Therefore, it is necessary to submit claims as per CMS guidelines.

How Does TPE Audit Work in Healthcare?

Selection: MAC selects the providers based on the analytical reports. Normally, the providers and medical practices with high denial rates are targeted.
Notification: The MAC notifies the selected provider via notification letter. The letter explains the audit process and requests for supportive documentation.
Claim Review: The MAC reviews the frequently denied claims and supported documentation. TPE audit in healthcare analyzes whether the submitted claim meets Medicare’s guidelines.
Results and Education: After sending the audit results to providers, the review program calls providers for one-on-one education. Similarly, MAC helps providers understand the potential billing risks and gives them time to correct them.
Follow-up: The provider is good to go if no error is found. However, if the mistakes continue, the provider undergoes further review rounds. In addition, these follow-ups help healthcare providers optimize revenue.

How to Handle TPE Audit in Healthcare?

Here are some tips for the provider to prepare for TPE audit rounds:

Review the Notification Letter: Review the notification letter from MAC and understand the reason behind the selection.
Prepare Documentation: Complete the documentation as mentioned in the review letter. In addition, prepare the documentation accurately to support the denial reasons.
Conduct Internal Audits: Conduct internal audits to learn about reasons for potential claim denial. The internal audit will help you understand the billing errors.
Stay Compliant: Follow the HIPAA regulations and stay compliant to avoid penalties. Preventing penalties leads to better revenue optimization in healthcare. If compliant, the physician will not be on the TPE list for at least one year.
Quick Response: MAC gives providers specific time to review claims and supportive documents. Therefore, submit documentation by the deadline. Typically, the provided time is up to 45 days.
Implement Feedback: Implement the feedback and education provided to you during the TPE review rounds. It will help you align with the CMS guidelines.

Conclusion

Medical practices can conduct internal audits to ensure accurate documentation. In addition, it is necessary for providers to stay HIPAA compliant, as per instructions from TPE audit in healthcare. Likewise, implement effective RCM strategies to reduce future billing errors.

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Frequently Asked Questions

How many days do MACs give providers to review the claim?

Typically, MACs give providers 45 days to review the claim. Furthermore, if errors remain, more days are given to streamline the claim submission process.

Does auditing help enhance financial growth?

Auditing helps identify the areas for improvement. By improving the suggested areas, a provider can sustain financial growth.

What happens if there are errors in the claims reviewed?

When the MACs observe errors and unusual billing patterns, they send a notification letter to the provider for review rounds.