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Aug 13, 2022 •695 likes •913 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

  1. 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 Gustafson, Manager, Noridian Kim Hinson, Director, Palmetto

  2. CMS National Provider Compliance Conference Prior to TPE • Probe Reviews • Service specific • Provider specific • Targeted Reviews • Service specific • Provider specific

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. CMS National Provider Compliance Conference

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. CMS National Provider Compliance Conference

  19. CMS National Provider Compliance Conference Change of Address • Part A/Part B – Applicable CMS 855 form • DME – Call or email NSC

  20. 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

  21. CMS National Provider Compliance Conference QUESTIONS?

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