Understanding Medicare’s Targeted Probe and Educate (TPE) Audits

Medicare’s Targeted Probe and Educate (TPE) audits are designed to identify and correct billing errors in a more “warm and fuzzy” manner compared to traditional audits. While the process might seem intimidating, understanding the TPE audit’s structure and requirements can help healthcare practices better prepare and respond. This comprehensive guide will break down the TPE audit process, common triggers, and provide practical tips to navigate these audits successfully.

What is a TPE Audit?

TPE audits target specific providers or suppliers and request a sample of 20 to 40 medical records. The aim is to review these records, provide feedback, and offer education to correct any identified errors. The process can involve several rounds of audits and education, depending on the provider’s compliance.

Common Triggers for TPE Audits

Medicare may initiate a TPE audit for various reasons, including:

• High Level of Services: Billing higher levels of service compared to peers.
• Volume of Services: Providing a high number of services, such as office visits or surgeries.
• Specific Services: Billing for services that are commonly misbilled or misunderstood.
• Impossible Day Scenarios: Unusually high patient visit numbers in a single day.

Real-World Example of a TPE Audit

An organization experienced a TPE audit focused on hospital admissions, specifically because Medicare determined their billing levels were higher than regional peers. The audit revealed documentation issues due to a mix of electronic and paper records, leading to incomplete submissions and initial failure.

Navigating the TPE Audit Process

1. Audit Notification: Ensure that the audit request reaches the appropriate compliance personnel promptly.

2. Record Review: Carefully review all requested medical records before submission to ensure accuracy and completeness. Confirm the correct date of service, provider, and patient details.

3. Education and Feedback: Pay close attention to the feedback provided by Medicare educators and implement recommended corrections.

4. Subsequent Rounds: If initial errors are identified, address them within the given timeframe (usually 45 days) before a second round of audits.

5. Continuous Improvement: Work closely with your providers to correct documentation processes and avoid repeated errors.

Potential Consequences of TPE Audits

If a practice fails to comply after three rounds of TPE audits, Medicare may impose stricter measures, such as:

• 100% Prepayment Review: Medicare reviews all claims before payment.
• Extrapolation: Medicare extrapolates errors found in a sample to a larger set of claims, potentially leading to significant recoupments.
• Referral to Recovery Auditors: More intensive audits that can result in substantial payment recoveries.
• Revocation of Billing Rights: In severe cases, Medicare may revoke the provider’s right to bill.

Expert Tips for TPE Audit Success

• Internal Audits: Conduct regular internal audits to identify and correct potential errors before Medicare does.
• Thorough Documentation: Ensure all medical records are complete and accurately reflect the provided services.
• Compliance Training: Regularly train your staff on compliance and documentation standards.
• Policy Review: Have clear, written policies for interpreting and documenting services to defend your practices during audits.

Conclusion

Understanding the TPE audit process and proactively addressing potential issues can significantly improve your practice’s compliance and audit readiness. By following the tips outlined above, healthcare practices can better navigate Medicare’s TPE audits and minimize the risk of severe consequences.

For more information on improving your practice’s compliance and audit readiness, contact Svast Healthcare Technologies.

Navigating Medicare’s TPE audits can be challenging, but with the right preparation and understanding, healthcare practices can ensure compliance and continue to provide high-quality care.