Noridian has released letters informing providers of a new pre-payment review called the TPEE- Targeted Probe and Education with Extrapolation review. This is a pilot program and if successful may become a part of the CMS integrity program.
Noridian states that this review will consist of a prepayment process designed to educate the provider of potential errors found. After the education process is completed, they will go to the next round and hopefully improve their results. This can continue for 3 rounds, and even a 4th if it is determined that this is necessary. Providers that continue to have a high denial rate after this process is completed may then be referred to a ZPIC or Recovery Auditor (RA) with extrapolation.
Practices with abnormalities in claims data or billing behaviors, or providers with abnormally high instances of a particular service may be identified for this process. Phlebology services are vulnerable in this analysis. The program integrity manual published by CMS includes the following description: “Identify high volume or high cost services that are being widely over utilized. This is important because these services do not appear as an outlier and may be overlooked when, in fact, they pose the greatest financial risk.”
More information on this program can be found at:
https://med.noridianmedicare.com/web/jfa/cert-reviews/targeted-probe-educate-with-extrapolation.
This news should cause practices to review their internal processes to ensure compliance with Medicare’s guidelines. Some more common items to review include medical necessity: Is your charting capturing all the necessary data? Code levels: Are you over-coding. Billing processes: Are you selecting appropriate diagnoses that are documented in your notes.
A couple more less common items to review include: Use limitations: Are you ordering more services than required or covered. FDA approval: Are you providing services that are off-label.
Typically each Medicare contractor provides readily available information on what they expect or require in regards to commonly billed services. At times they can be vague or non-existent, and when this is the case, other references can be reviewed to determine if a practice may be at risk. Nationally recognized LCD’s and Coverage Policies are a good place to start. All practices should have a good internal audit policy in place, and this should be performed annually to decrease risk of non-compliance.
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