CMS revamps claims review process

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Wednesday, August 16, 2017

WASHINGTON – Claims submitted by providers that have the highest claim error rates or billing practices that vary significantly from their peers will soon face increased scrutiny, CMS has announced.

As part of an expanding “Targeted Probe and Educate” program, the Medicare Administrative Contractors will identify these providers through data analysis.

“TPE claim selection is different from that of previous probe and educate programs,” the agency stated in an Aug. 14 announcement on its website. “Whereas previously the first round of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset. This eliminates burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.”

Per the program, the MACs will review 20 to 40 claims per provider, per item or service, per round, for a total of up to three rounds of review. After each round, providers will be offered individualized education based on the results of their reviews.

Providers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 reviews, followed by additional education. Providers with high error rates after the second round will continue to a third and final round of reviews and education.

Providers with continued high error rates after three rounds of review may be referred to CMS for additional action, which may include 100% pre-pay review, extrapolation, referral to a Recovery Auditor Contractor, or other action.

Providers may be removed from the review process after any of the three rounds of review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.

The program began as a pilot project in one MAC jurisdiction in June 2016 and was expanded to three additional jurisdictions in July 2017. CMS will expand the program to all jurisdictions later this year.