The tagline from the CMS Website is “When Medicare Claims are submitted accurately, everyone benefits.”

First – TPE why do we even care?  Well, simple answer, it is a lovely little gift from CMS designed to help reduce claim denials and appeals through one-on-one help.  As we can attest thorough masses of audits of provider medical records and claims, many common errors are easy to correct such as including a missing provider’s signature. From October 2018 to September 2019, CMS approximates that:

  • 13,500 providers received a TPE notice of review
  • 435,000 claims were reviewed
  • 40% of claims reviewed were rejected as billed (leading to additional direct and indirect costs to the provider submitting the claim)

The CMS tells us that Most providers will never need TPEAdditionally this website tells us that:
Medicare Administrative Contractors (MACs) use data analysis to identify:

  • providers and suppliers who have high claim error rates or unusual billing practices, and
  • items and services that have high national error rates and are a financial risk to Medicare.

What are some common claim errors?

We would like to focus on the most common one that we see for commercial payer audits, which is documentation not meeting medical necessity – this is a particular hot button we focused on recently. We have always taken the stance that medical necessity is a salient part of the audit. Medical necessity is not always about the service itself, but the documentation that justified the service.

Again, after auditing millions of claims, we can tell providers that sending accurate, complete, and organized records the first time of an audit, the chances of passing are increased.  However, you can have a well-organized record, but if the MDM is not there, or the documentation isn’t accurate, complete and organized files will not get you to pass.

Other ways to help the chances of passing self-audits is to perform proactive analytics and make corrections as they are identified through these steps. 

Simply, chances of passing are also higher, if a provider can show that corrections are implemented swiftly and effectively after education is given. 

To our readers, here’s a fun fact to leave you with: a provider/supplier be included in multiple TPE probes at the same time if a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review. TPE season, is right around the corner, we look forward to everyone more accurate submissions and everyone benefiting.