Medicare TPE Audits: What Providers Need to Know

The Facilities for Medicare and Medicaid (CMS) has designed the Focused Probe and Educate (TPE) program to assist suppliers and suppliers cut back declare denials and appeals by offering one-on-one assist. The CMS resumed TPE audits in September 2021 after suspending the TPE program in the course of the earlier phases of the COVID-19 pandemic. For healthcare suppliers focused in these audits, understanding what to anticipate—and the way to put together successfully—might be important for avoiding pointless penalties. Whereas TPE audits usually are not enforcement mechanisms as such, suppliers which might be present in non-compliance in the course of the TPE audit course of can face follow-up enforcement motion, and this could probably lead to recoupments, prepayment evaluation, and different penalties. 

Because of this, Medicare-participating healthcare suppliers which might be dealing with TPE audits want to deal with their conditions fastidiously. Providers can’t assume that TPE audits are trivial or inconsequential. Whereas they could be for suppliers which have a robust compliance report and the documentation to show it, they may also be harmful if not dealt with successfully. 

“Facing a Medicare TPE audit isn’t necessarily as straightforward as it may seem. While these audits ostensibly focus on education and correction, issues uncovered during TPE audits have the potential to lead to CMS enforcement action if targeted providers do not address them effectively.” – Dr. Nick Oberheiden, Founding Lawyer of Oberheiden P.C.

So, what do healthcare suppliers want to find out about Medicare TPE audits in 2022? Listed here are a few of the highlights: 

1. The Focus of a Medicare TPE Audit is “Improvement” 

In accordance to CMS, the objective of a TPE audit is to assist the focused supplier “quickly improve.” This refers particularly to bettering the focused supplier’s billing compliance charge. Billing fraud prices CMS tens of billions of {dollars} yearly; and, whereas some circumstances of billing fraud are intentional, many contain inadvertent errors that outcome from failure to undertake an efficient Medicare billing compliance program

2. Medicare Administrative Contractors (MACs) Conduct TPE Audits for CMS

As CMS additional explains, throughout a TPE audit, “Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple . . . and are easily corrected.” Medicare Administrative Contractors are personal corporations that work with CMS to uncover billing violations. They’ve entry to suppliers’ billings submitted to Medicare, they usually have the authority to receive and evaluation suppliers’ billing data on CMS’s behalf. 

TPE audits are supposed to assist suppliers deal with simply correctable errors that aren’t indicative of intentional Medicare fraud. Schooling is a key facet of the method—in distinction to non-TPE Medicare Administrative Contractor (MAC) audits throughout which suppliers will usually battle to perceive why they’re being penalized. When conducting TPE audits, MACs are supposed to work collaboratively with suppliers to both (i) affirm that the suppliers’ billing practices are compliant, or (ii) establish and implement particular obligatory enhancements. 

3. MACs Choose Providers for TPE Audits Based mostly On Their Billing Information

Medicare Administrative Contractors don’t select suppliers for TPE audits at random. As an alternative, MACs analyze suppliers’ billing knowledge and select targets for TPE audits based mostly on a number of of the next elements: 

  • Excessive Declare Error Charges

  • Uncommon Billing Practices

  • Billing for Objects or Providers that Have Excessive Nationwide Error Charges 

Provided that that is the case, whereas it’s attainable {that a} TPE audit might end in a discovering of compliance, MACs typically go into TPE audits with the expectation that they are going to establish flaws within the supplier’s Medicare billing compliance practices and procedures. That is essential to be mindful—though TPE audits are supposed to be non-adversarial and academic in nature, suppliers will nonetheless usually discover themselves struggling to persuade MACs that no corrective motion is warranted. 

4. Medicare TPE Audits are Topic to Strict Guidelines

Not like different kinds of Medicare compliance audits, TPE audits are topic to strict rules. For instance, the Medicare Administrative Contractor (MAC) could solely choose 20 to 40 claims for evaluation, and it could solely request that the focused supplier provide supporting medical data for these particular claims. If the MAC determines that these 20 to 40 claims are compliant, the method ends. Nevertheless, if the MAC determines that any of the topic claims violate the Medicare billing guidelines, the method will proceed. 

5. Points Uncovered Throughout a TPE Audit Will Lead To an “Education Session”  

As soon as a MAC determines that a number of of a focused supplier’s topic claims are non-compliant, the MAC and the supplier should schedule an “education session.” In accordance to CMS, “experience has shown that this education process is well received by providers/suppliers and helps to prevent future errors.” Whether or not or not that is really the case is up for debate. In any occasion, MACs and suppliers should each take part within the schooling session in good religion; and, following the schooling session, the supplier should be given at the very least 45 days to deal with any compliance points earlier than dealing with the second spherical of evaluation of one other 20 to 40 claims. 

6. Providers Get Three Probabilities to Cross a TPE Audit

Providers can undergo this course of up to thrice. If a supplier passes the audit at any stage, then the supplier is entitled to a one-year reprieve from dealing with one other TPE audit. However, there are exceptions. Throughout this one yr, the supplier can nonetheless probably face a TPE audit focusing on a special space of billing compliance, and CMS states that “MACs may conduct an additional review if significant changes in provider billing are detected.” 

With this in thoughts, when dealing with Medicare TPE audits, healthcare suppliers ought to take the time to conduct a complete evaluation of their billing processes and procedures. Even when a supplier addresses the difficulty (or points) uncovered throughout a TPE audit, this is not going to essentially be sufficient to shield the supplier from additional scrutiny—or penalties. Medicare-participating suppliers want to take a complete strategy to billing compliance, they usually can’t afford to depart the end result of future audits (or investigations) to likelihood. 

7. Providers that Fail TPE Audits Will Be Referred to CMS

If a supplier fails to go a TPE audit after three rounds of declare critiques, schooling classes, and course of enhancements, the MAC will refer the supplier to CMS. Because the company explains, “any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.” Relying on the problems recognized in the course of the TPE audit, this “other action” might vary from an in-depth billing compliance audit to a legal Medicare billing fraud investigation. 

8. Quite a few Billing Points Can Lead to Medicare TPE Audit Failures 

Usually talking, Medicare TPE audits concentrate on a selected billing challenge, corresponding to lacking doctor signatures or inadequate documentation of medical necessity. Nevertheless, TPE audits can goal all kinds of Medicare billing violations; and, if a MAC identifies a billing challenge throughout a TPE audit, it actually isn’t going to let the difficulty go ignored. Because of this, even when a Discover of Evaluation signifies {that a} TPE audit will concentrate on a selected billing challenge, it’s not secure to assume that that is the one challenge that has the potential to lead to issues. Some extra examples of frequent Medicare billing violations embrace: 

  • Lacking or incomplete certification or recertification paperwork 

  • Billing for gadgets or companies Medicare doesn’t cowl

  • Billing for gadgets or companies not truly offered to sufferers 

  • Upcoding, unbundling, clustering, and different coding violations 

  • Failure to use coding modifiers 

9. Failing a TPE Audit Can Have Important Penalties 

As mentioned above, whereas Medicare TPE audits usually are not essentially supposed as enforcement instruments, suppliers that fail their TPE audits can face important penalties. Focused Probe and Schooling audits can lead to complete Medicare billing compliance audits, they usually can even lead to federal billing fraud investigations. The Facilities for Medicare and Medicaid Providers even have the choice to straight impose sure administrative penalties, corresponding to prepayment evaluation, with out extra inquiry. 

If a complete Medicare billing compliance audit or a billing fraud investigation leads to civil allegations of Medicare fraud, the focused supplier can face recoupments, fines, Medicare exclusion, lack of Medicare billing privileges, and different penalties. If an audit or investigation leads to legal prosecution by the U.S. Division of Justice (DOJ), the focused supplier (and probably its house owners, executives, physicians, and different personnel) can face these identical penalties plus the potential for federal imprisonment.

10. Providers Can (and Ought to) Put together to Defend In opposition to TPE Audits

Given the dangers related to dealing with a TPE audit, Medicare suppliers want to put together for these audits successfully. Despite the fact that CMS describes the TPE audit course of as a collaborative engagement between the auditing MAC and the focused supplier, suppliers ought to strategy TPE audits with a defensive mindset. They need to assume that any unfavorable findings might be used in opposition to them; and, with this in thoughts, they need to focus their efforts on proactively resolving their TPE audits with out referral to CMS. 

These are simply a few of the key concerns for healthcare suppliers which might be dealing with TPE audits. To make sure that they’re making knowledgeable choices and defending their practices to the fullest extent attainable, suppliers ought to interact federal healthcare fraud protection counsel promptly upon receiving a Discover of Evaluation.

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