What is a TPE Audit in Healthcare?

Targeted Probe and Educate (TPE) is a program established by Medicare in 2017 to help doctors minimize the number of denials and educate them to avoid mistakes in claims. It was noticed that providers were struggling a lot with claim denials, so after data analysis, CMS decided to build a program that helps providers identify common errors in claims and avoid them in the future, but calling it purely an educational program is not true. Many healthcare providers are unfamiliar with this program due to the pause taken in 2019. At the beginning of this program, many providers were enrolled to improve their claims. However, the management had to hold the program due to COVID-19, and they have not enrolled more doctors.

For healthcare providers who do not know what TPE is or have never experienced its audit, there is a possibility you can experience it soon. Our article will help you understand the basic concept of TPE. We have mentioned all the possible points that could be the reason for a TPE audit in your practice. You will learn the process involved in TPE audit and why it is necessary.

Reasons for TPE Audit?

Medicare TPE audit is an examination program examining providers’ billing practices for claims. This audit is conducted by the Medicare Administrative Contractor (MAC) to identify the discrepancies in the billing process. MAC conducts the audit to help providers fix the problems found during the audit and educates them on how to avoid them in the future. MAC only chose those practices for whom they noticed errors in their claims. A few common reasons for MAC Audits are here:

A high number of claim denials
Plenty of errors in the claims submitted
Unusual billing mistakes
Services with high national error rates

Reasons for TPE Audit?

MAC reviews 20-40 claims submitted by the providers, including medical examinations and procedures mentioned in the claim. If MAC finds errors during the audit, the provider will be invited to a one-on-one session. In this session, he will be trained to improve the mistakes in the next 45 days. If the claims are compliant, the practice will not face an audit for the specific reason, at least for the next year. Healthcare providers who have participated in the TPE audit program have improved their mistakes and gained accuracy in their billing process. There are three rounds of a TPE audit program, but if any provider does not improve after these rounds, they will have to undergo further training at CMS. Here, we have discussed the whole TPE process:

MAC Audit Notice

Healthcare providers receive written notice from the MAC, in which they mention the reason for the audit and the claims that will be audited. After that, providers receive another email for ADR, in which the MAC mentions the required documents from the provider. MAC has certified medical coders and auditors who perform these TPE audits.

1st TPE Audit Round

In the first audit round, MAC audits 20 to 45 claims of a specific type. If MAC finds the claims compliant, there will be no second audit round. MAC will not take any action, and the practice will not be audited for at least 12 months for the same type of claim.

2nd TPE Audit Round

The practice will be sent to the second round if there are still errors after the first audit. The MAC will review the results of the audits performed in the first round, in which they check if the patient’s documents are complete, the codes are accurate, the patient’s information is complete, the patient is eligible, the provider is credentialed, and compliant. The MAC shares analysis reports with the practice and explains why they have failed the first round. MAC offers a one-on-one practice session during which they will educate on how practices can improve these mistakes. Now, the provider has 45 days to improve their mistakes after this session. MAC again reviews the practice after a specific interval with the same pattern.

3rd TPE Audit Round

This is the final audit round from TPE. Most providers improve their mistakes after two rounds, but if MAC concludes that the practice is not improving, it will recommend them to CMS for further training.

Common Errors MAC Looks During The Audit

Initially, providers were not aware of the CMS rules, regulations, and parameters of what MAC puts the practice into observation. Here, we have mentioned common reasons for claim denials and some major points that trigger MAC’s attention toward a practice for TPE audit:

Reasons for Claim Denials

Claim submitted without physician’s authorized signature
Missing necessary documents
Patient eligibility is not confirmed
Missing documents of provider’s credentialing

Parameters of MAC During an Audit

Repetition of CPT codes in the claims, regardless of the patient’s condition or diagnosis
Using general codes for different types of diagnoses
No progress in codes (using the same codes for a long time after multiple visits)
Using high payment codes
Using the wrong National Provider Number (NPI)
Cases of Upcoding or Downcoding

Tips to Avoid TPE Audits in the Future

Providers can avoid TPE audits with a few improvements in their practice, which we have mentioned below:

Stay Compliant

Practices should train their billing team to process claims according to CMS healthcare compliance and regulations when preparing medical claims. The information mentioned in the claims should be accurate and up-to-date. Providers who manage their medical billing in-house should keep a close eye on the accuracy of the claims.

Establish Some Checkpoints

Establishing checkpoints for claim submissions is a helpful technique for practices to maintain accuracy and avoid TPE audits. These checkpoints will help them discover the minor to major errors in the claims. The checkpoints can be the following:
Providers signature

Only the performed services, procedures, and medications are coded
The diagnosis is accurate and completely mentioned
Codes are up-to-date according to the diagnosis and procedures

Along with these checkpoints, practices are recommended to conduct regular internal billing audits to ensure that their claims are compliant and error-free

Conduct External Audits

Practices can significantly avoid TPE audits by conducting external medical billing audits. Providers can consult the experts like Physicians Revenue Group, Inc. for audit services. These experts perform detailed audits and offer thorough audit reports. Additionally, it help providers discover areas for improvement, ultimately increasing cash flow and improving revenue cycle and healthcare financial management.

Final Words

What if you won’t get paid for the services rendered because of claim errors and multiple denials? In this article, we have mentioned how providers should respond to the TPE audit invitation, the steps of the TPE audit, tips for the providers to clear this audit, and how providers can avoid them. Here, you will understand the process of a TPE audit in detail and get important tips on minimizing claim denials and conducting external medical billing audits, resulting in increased reimbursements.