03/02/2022    J. Kevin West, Esq.

Medicare TPE Review

Query: Medicare TPE Review

I received notice I am being selected for a TPE
(targeted probe & education) review by Novitas
Medicare. I practice in New Jersey. I have gone
over the LCDs and the “educational” materials they
sent. My documentation seems to be aligned with
what they want. Any advice for working with them to
have this resolved as soon as possible? Any things
to avoid? Should I have someone other than myself
act as a liaison between Medicare and me?

PM News Subscriber

Response: I am currently handling a large number of
TPE audits across the country. Almost all of them
relate to CPT codes 11720-21, 11719 and 11055-57.
These are typically prepayment audits, meaning that
following receipt of the notice of review, the
doctor will get 20-40 separate Additional
Development Request (ADR) letters asking for copies
of medical records for claims that have been
submitted but not yet paid/denied by Medicare. This
initial group of ADR letters is considered to be
“Round 1” of the TPE audit. If the doctor gets a
passing score on Round 1, the audit ends; if the
doctor fails Round 1, the Medicare contractor
offers an opportunity for an “educational call”
with the doctor and allows a period of time for
corrective action to be taken. After that, Round 2
begins and the doctor will receive 20-40 more ADR
letters and the process repeats itself in Round 2
and potentially Round 3. If a doctor fails all
three rounds, there will likely be a more serious
and expanded audit by another contractor, such as a
Program Integrity contractor. This would
potentially be a large extrapolated audit and
involve many services and potentially a large
overpayment. Obviously, you do not want this to
happen.

When I am assisting a doctor in a TPE audit, the
goal is to pass in Round 1 and end the audit
quickly. I use coding consultants to review the
doctor’s records so that we can identify
documentation problems and fix them going forward.
Note that we cannot change existing chart notes,
but we can correct and improve documentation going
forward. One problem is that different TPE auditors
have different definitions of what error rate
constitutes a failure to pass in a given round of
the TPE. I have been told by one auditor that a 20%
error rate is a failure, but another auditor has
said 10% is the benchmark. Last week I had a doctor
get 38 out of 40 services approved (a 9.5% error
rate) in Round 1 and the doctor still failed! I
will be talking to the auditor about that one,
which I think is totally wrong and unfair. Most
doctors do pass with a result like this.

I have no problem with doctor engaging in
educational sessions with Medicare personnel by
telephone, as long as they realize that Medicare
contractors may portray themselves as your
“friends,” and the doctor should not let his/her
guard down and make admissions that could later be
used against them. Note that these calls are
recorded. In addition, while some Medicare auditors
are well informed and quite helpful, some are not,
and even well meaning contractor personnel can
mislead you. My coding expert and I typically
participate in these calls with the doctor to avoid
the problems just mentioned, and I usually find
that the auditors are on their best behavior when
we show up.

I strongly encourage doctors to notify their
insurers immediately when they get notice of a TPE
audit. Handling on your own is not wise. The
biggest key is getting a good coding expert quickly
involved to look at the doctor’s notes and
proactively identify and correct any problems going
forward so that Round 1 can be successfully passed.
I am happy to report that none of my clients have
ever failed all three rounds and most pass in the
first or second round, again, thanks to the efforts
of the coding experts.

I hope this report from the “front lines” is
helpful.

J. Kevin West, Esq., Boise, ID

There are no more messages in this thread.