“What are the Most Common Medicare and Medicaid Audits and Which One is the Least Aggressive?”
Types of Medicare and Medicaid audits include:
Targeted Probe & Educate (TPE) Program audits.
Unified Program Integrity Contractor (UPIC) audits.
Supplemental Medical Review Contractor (SMRC) audits.
Comprehensive Error Rate Testing (CERT) audits.
Recovery Audit Contractor (RAC) audits.
The least aggressive Medicare and Medicaid audit is the Targeted Probe & Educate (TPE) Program audit.
As the name suggests, TPE audits are intended to educate Providers on specific billing issues to increase accuracy and reduce claim denials and appeals, but they can also result in penalties. During TPE audits, Providers are subject to up to three rounds of claims reviews (both pre-payment and post-payment) and individualized education. Medicare Administrative Contractors (MACs) target Providers identified through data analysis as having high claim error rates or unusual billing practices compared to their peers.
CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.
The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple – such as a missing physician's signature – and are easily corrected.
Most providers will never need TPE.
TPE is intended to increase accuracy in very specific areas.
MACs use data analysis to identify:
1. providers and suppliers who have high claim error rates or unusual billing practices, and
2. items and services that have high national error rates and are a financial risk to Medicare.
Providers whose claims are compliant with Medicare policy won't be chosen for TPE.
What are some common claim errors?
1. The signature of the certifying physician was not included
2. Documentation does not meet medical necessity
3. Encounter notes did not support all elements of eligibility
4. Missing or incomplete initial certifications or recertification
How does it work?
1. If chosen for the program, you will receive a letter from your Medicare Administrative Contractor (MAC)
2. The MAC will review 20-40 of your claims and supporting medical records
3. If compliant, you will not be reviewed again for at least one year on the selected topic
4. If some claims are denied, you will be invited to a one-on-one educational session
5. You will be given a least a 45-day period to make changes and improve
6. MACs may conduct additional review if significant changes in provider billing are detected
What if my accuracy still doesn't improve?
This should not be a concern for most providers. The majority that have participated in the TPE process increased the accuracy of their claims. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.
This is my opinion.
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