“I received notice I am being selected for a TPE (targeted probe & education) review by Novitas Medicare. I practice in New Jersey. I have gone over the LCDs and the “educational” materials they sent. My documentation seems to be aligned with what they want. Any advice for working with them to have this resolved as soon as possible? Any things to avoid? Should I have someone other than myself act as a liaison between Medicare and me?”
As a general rule, Medicare audits physicians based upon two premises, trends and patterns. If a physician of a certain specialty is billing something more frequently than the other physicians of the same specialty in the same billing region/state or is billing for something totally different than the other physicians of the same specialty in same billing region/state, this often is what triggers the audit.
A Targeted Probe and Education or TPE is usually based upon the above rationale on the part of the Medicare Administrative Carrier of the provider in question. The provider is informed of what the issue or issues are and of course is provided with the specific CPT codes, E/M codes, or modifiers that are being questioned and investigated. The TPE process can take up to three rounds of a prepayment claim review with education. If there are continued high denials, the Medicare Administrative Carrier, in this case, Novitas, can refer the provider to CMS for additional action, which may include 100% prepayment review, extrapolation, or a referral to a recovery auditor. The review can be discontinued at any time if appropriate improvement is achieved during the claim review process. The TPE process will usually start off with a set number of claims to be reviewed, generally 10. If the first 10 claims do not have any errors, the TPE process will end for that specific issue. However, if any errors are found within the first 10 claims, then the TPE process continues.
Do not submit any documentation until you are specifically asked to do so. The provider should receive an Additional Documentation Request Letter or ADR for each claim selected for review. The letter includes a list of specific elements needed to support the issues that are being reviewed (ie, CPT codes, E/M codes, appropriate use of modifiers). The provider is provided with a time frame to submit the requested information and this needs to be followed precisely or the claim in question will be denied and will add to the error rate.
From an education standpoint, the provider will be provided with a variety of methods that are appropriate to use. If curable errors are identified during the claim review, then the provider will be contacted to participate in this step of the process.
As far as working with Novitas to have this situation resolved ASAP, this is really out of the hands of the provider. You are dealing with the government and they move at their own pace.
As far as anything to avoid, I would be hesitant to contact Novitas to discuss any of these issues with them. Anything that you say can be held against you. I would follow the written instructions specifically and precisely. I would absolutely follow the time frames that you are provided with to submit ALL of the requested information that is asked for. I would absolutely, positively, unequivocally NOT change or add anything to the documentation for the date(s) of service in question.
As far as having someone other than the provider act as a liaison between the Medicare Administrative Carrier, in this instance Novitas and the provider, if your malpractice carrier is PICA, you do have Administrative Defense Coverage and I would certainly call PICA ASAP. If you have another malpractice insurance company, I would certainly call them and find out if you are provided with Administrative Defense Coverage. I don’t know specifically what the issues at hand are and the extent to what degree Novitas is exploring, but it might not be a bad idea to speak to a health care attorney. Since a pretty fair portion of what I do is classified as forensic medical coding and I have participated in similar situations on a coding level, I am not an attorney and that is probably a good place to start.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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