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    Everything doctors need to know about new payment review strategies

    In an August 2017 notification to providers and suppliers, the Centers for the Medicare & Medicaid Services (CMS) communicated changes to its medical review and education strategy. CMS will now concentrate its efforts using a program called “Targeted Probe and Educate”(TPE).  

    Medicare Administrative Contractors (MACs) will identify and selectively audit individual providers with outlier service billing patterns, rather than audit all providers billing the identified service. 

    If you are identified as having billing practices that vary significantly from your peers, your MAC may conduct a probe sampling of 20 to 40 claims per service item. If, after such review, an unacceptable error note is determined, individual training will be provided for each reviewed item. 

    If a provider sufficiently improves after any one of the reviews, that item will not be reviewed again for 12 months. However, if no improvement is made after three rounds, the provider will be referred to CMS for further action (e.g.,100% prepay review, extrapolations, referral to a recovery auditor or other actions). 

    While the impact of the TPE program is unknown, some of our clients have encountered commercial payers already using similar strategies. As these inquiries do not always include a documentation review, providers should be aware of these varying notices and prepare to respond accordingly.

    For example, when commercial payers conduct data analyses to compare providers’ evaluation and management (E/M) coding levels to that of their peers, they may find a few providers who fall outside the norm. Some physician practices have reported receiving letters identifying them as outliers due to billing pattern data that show they are billing higher levels of E/M—office or hospital visit—codes than their peers.

    Interestingly, these payer letters often are sent to create awareness and not to request documentation for conducting an audit. Payers are using this “soft approach” to educate, and subsequently monitor, practices before resorting to time-consuming, expensive documentation audits. 


    Contacting outside help 

    A practice may or may not have the internal capacity to perform E/M coding reviews. Even when a practice employs a coding professional, it may request an external review for various reasons. The table outlines a few of the pros and cons of conducting internal versus external reviews.


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