Name Educate (TPE) Laura Minter, Senior Director, Novitas Title - - PowerPoint PPT Presentation

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Name Educate (TPE) Laura Minter, Senior Director, Novitas Title - - PowerPoint PPT Presentation

Aug 13, 2022 695 likes •914 views

CMS National Provider Compliance Conference CMS National Provider Compliance Conference OPENING REMARKS Targeted Probe and Name Educate (TPE) Laura Minter, Senior Director, Novitas Title Ronda Tipton, Manager, CGS Organization Shanda

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CMS National Provider Compliance Conference

OPENING REMARKS

Name

Title Organization Laura Minter, Senior Director, Novitas Ronda Tipton, Manager, CGS Shanda Gustafson, Manager, Noridian Kim Hinson, Director, Palmetto

Targeted Probe and Educate (TPE)

CMS National Provider Compliance Conference

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CMS National Provider Compliance Conference

Prior to TPE

  • Probe Reviews
  • Service specific
  • Provider specific
  • Targeted Reviews
  • Service specific
  • Provider specific
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CMS National Provider Compliance Conference

Probe Review

  • Provider specific: 20-40 claims reviewed
  • Education at end of probe via letter and/or web posting
  • Service specific: 80-100 claims reviewed
  • General education provided via web posting; not specific to one

facility/provider/supplier

  • Move to targeted review if high errors
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CMS National Provider Compliance Conference

Targeted Review

  • Larger percent of claims were reviewed
  • Removed from review when a decrease in errors was demonstrated
  • Education provided at least every six months
  • Via letter and/or web posting
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CMS National Provider Compliance Conference

What is TPE?

  • Result of Change Request (CR) 10249
  • Implemented nationally on October 1, 2017
  • CMS authorized MACs to conduct TPE process
  • Provider specific reviews
  • Includes up to three rounds of reviews with individual education
  • Minimum 20 claims and maximum 40 claims per round
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CMS National Provider Compliance Conference

Goal of TPE

  • Decrease billing errors
  • Decrease appeals
  • Decrease provider burden
  • Increase education
  • One-on-one
  • Before, during, and after probe
  • Provide time for error correction prior to next round
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CMS National Provider Compliance Conference

Focus of TPE

  • Specific facilities/providers/suppliers
  • Data analysis
  • CERT errors
  • Referrals
  • Bill particular service or item
  • High national error rate
  • Financial risk to Medicare
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CMS National Provider Compliance Conference

How TPE Works

  • Notification of review
  • Additional Documentation Requests (ADRs)
  • Request documentation for 20-40 claims
  • DME - 10 claim preview pilot
  • Claim review completed
  • Education offered
  • Findings of review
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CMS National Provider Compliance Conference

Notification

  • Varies across MACs
  • In writing via letter
  • Explanation of the TPE process
  • Service/topic/item selected for review
  • Reason for selection
  • MAC contact information
  • Notification of intent for individual education
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CMS National Provider Compliance Conference

Additional Documentation Requests

  • ADR for claims selected per usual process
  • Part A
  • Mail
  • Portal, if available
  • Fiscal Intermediary Standard System (FISS)
  • Part B and DME
  • Mail
  • Portal, if available
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CMS National Provider Compliance Conference

Response to ADR

  • Documentation sent to MAC within 45 days by
  • Mail
  • Hardcopy
  • CD/DVD, password protected
  • Fax
  • esMD
  • Visit Electronic Submission of Medical Documentation (ESMD) on CMS website
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CMS National Provider Compliance Conference

Preparing Documentation

  • Do place ADR first (on top of medical records)
  • Do ensure all requested documentation is included
  • Do include legible signatures or attestation/signature log
  • Do not include documentation that does not pertain to ADR
  • Do not use staples or paperclips
  • Do not mix single sided and doubled sided documents
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CMS National Provider Compliance Conference

Claim Reviews

  • Medical Review (MR) Timeliness
  • Prepayment claim reviews: 30 days
  • Postpayment claim reviews: 60 days
  • Courtesy calls may occur for missing documentation and/or for

easily curable errors

  • Process claim with review determination
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CMS National Provider Compliance Conference

Education

  • MR offers education on errors via:
  • Letters/Correspondence
  • Teleconference calls
  • One-on-one call with details of errors and education on service
  • Electronic visit (Evisit)
  • Call with details of errors and education on service via webinar
  • Provider/Supplier report cards
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CMS National Provider Compliance Conference

Closing/Results Letter

  • Varies across MACs
  • Summary of probe review
  • Detailed review of claim findings
  • General educational information
  • Next steps in TPE process
  • MAC contact information
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CMS National Provider Compliance Conference

Moving On

  • TPE process includes up to three rounds
  • Subsequent rounds occur at least 45 days after MR education provided
  • Any problems that fail to improve after three rounds of review/education

will be referred to CMS for next steps which could include

  • 100% prepayment review
  • Extrapolation
  • Referral to a Recovery Auditor
  • Other action
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CMS National Provider Compliance Conference

Change of Address

  • Part A/Part B – Applicable CMS 855 form
  • DME – Call or email NSC
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CMS National Provider Compliance Conference

Resources

  • Internet Only Manual (IOM) 100-08 Chapter 3, Section 3.2.5
  • CMS website
  • Targeted Probe and Educate FAQ
  • TPE Flow Chart
  • MAC websites
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QUESTIONS?