Breaking News: CMS Targeted Probe and Educate Medical Review Strategy Expansion

Posted by Kathy Dean on 08/15/2017

The Centers for Medicare and Medicaid Services (CMS) announced on 8/14/2017 that they will be expanding the probe and educate program.  CMS started a program in 2014 for complex medical review of claims with the medical record along with education to the provider to help reduce billing errors.  CMS uses the Medicare Administrative Contractors (MAC) for these targeted clinical documentation reviews in order to prevent improper billing and payments.   The MAC chooses the claims that will be reviewed based on many things such as data analysis reports, billing patterns and improper payment data for specific service areas.

CMS calls these reviews, Probe and Educate.  CMS has identified that the results of the audits have been favorable, based on the decrease in the number of claims errors after the provider was educated. CMS states they are now going to further improve this strategy by moving from a broad Probe and Educate program to a more targeted probe and educate (TPE).  CMS says these TPE reviews focus on specific providers and suppliers within the service rather than all provider and suppliers billing a particular service.  

A Provider-specific probe occurs when an issue has been identified through data analysis that is specific to one provider. The review usually includes a 20 to 40 claims sample from the selected provider. The sample of claims selected will be based on the focus of the review (e.g., specific service or billed by the selected provider).

A Service wide probe occurs when an issue has been identified through data analysis that is not specific to one provider. That is, the issue affects providers in a state, multiple states, or jurisdiction.  Service Wide Probes usually include a 50-100 claims sample, in total from the state, multiple states or jurisdiction. The sample of claims, from multiple providers, is selected based on the focus of the review (e.g., specific service(s) billed).

CMS states that as a result of the successes demonstrated during the pilot, including an increase in the acceptance of provider education as well as a decrease in appealed claims decisions, they have decided to expand to all MAC jurisdictions later in 2017.

Providers and suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action, CMS says. After any of the three rounds of the probe review, providers and suppliers may be removed from the review process, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS. 

To read more on how the future nationwide program will be implemented and claims will be selected go to the following CMS weblink.  There is also a probe and educate flow chart on this website at the bottom of the page.