Targeted Probe and Educate Pilot

on Tuesday, 15 August 2017. All News Items | MAC Reviews

How Do You Define Success

Medicare is expanding the Targeted Probe and Educate (TPE) pilot program. You may not have even realized that anything related to Probe and Educate was still around, but CMS began using Probe and Educate reviews for home health agencies in November 2015.  In Transmittal 1861 CMS expands the existing Targeted Probe and Educate (TPE) Pilot to include three additional contractors, Jurisdictions B, D, E, and F. According to the transmittal, “The purpose of this expansion is to test the TPE strategy for Durable Medical Equipment (DME) as well as urban regions.” 

What I find surprising is a statement in the transmittal that says, “The 2014/2015 MAC (Medicare Administrative Contractor) Probe & Educate medical review strategy for hospital inpatient status cases produced favorable outcomes with respect to educating providers/suppliers and reducing improper payments.”  This makes it sound as if the MAC Probe and Educate program was a huge success.  Really?  I realize the focus of these MAC reviews, which was review of short-stay inpatient admissions to determine compliance with the new 2-midnight rule, was a tremendous challenge in itself due to lack of clarity in Medicare’s guidance. The Probe and Educate program was first announced in September 2013 to address claims from October 1, 2013 through December 31, 2013.  This time frame was quickly expanded to March 31, 2014 – the plan was initial reviews for 3 months, then education followed by another round of reviews.  The time frame was extended again through September 2014 and MACs were directed to re-review already denied claims based on recent clarifications of the 2-midnight rule. Over the next several months, the review was extended 3 more times before being transitioned away from the MACs altogether to the Quality Improvement Organization (QIO) contractors beginning October 5, 2015.  In defense of the MACs, the QIOs have also struggled with understanding, applying and educating providers on the 2-midnight rule requirements.

Whether you consider the original MAC probe and educate program a success or not, CMS is moving forward with the pilot expansion. Jurisdictions B and D are DME MACs, but Jurisdictions E and F are Part A/B contractors that cover the western states. Noridian Healthcare Solutions has the contract for both the JE and JF jurisdictions.  Due to positive results from an existing pilot and modifications to existing programs “from lessons learned,” CMS expects “this strategy will demonstrate measurable reductions in the number of claims denied and the number and merit of appeals.”

In the new and better TPE, CMS is allowing MACs to select their review topics, based upon their own strategies. They are also modifying the size of the probes and the way education is provided to improve effectiveness.  The key elements of the TPE pilot are:

  • It replaces all current complex and routine reviews in the MAC’s Improper Payment Reduction Strategy (IPRS) with three rounds of a pre-payment Targeted Probe & Educate process,
  • High denial rates after 3 rounds will result in referral to CMS for additional action, such as extrapolation or referral to the ZPIC/UPIC or RAC,
  • MACs can target high-risk providers rather than reviewing all providers, and
  • The sample for each probe “round” is limited to 20-40 claims.

The pilot MACs will discontinue all traditional complex reviews, routine reviews, and documentation compliance reviews. They may continue automated reviews, comparative billing reports, other pilot review strategies, and can perform limited medical reviews with ZPIC referral if there is suspicion of fraud and abuse. If the TPE Pilot proves effective, it may be expanded to other MAC jurisdictions. 

Both Noridian E and F ( ) have announcements on their Medical Review webpage about TPE that provide some additional details.

  • Noridian will select the topics for review and providers based on existing data analysis procedures outlined in the Medicare Program Integrity Manual, Chapter 2.
  • Noridian will notify providers in writing on the topic being reviewed, data reasons for selection, and process of review.
  • If providers do not respond to ADR requests by submitting the requested documentation, Noridian may refer them to the RAC or ZPIC/UPIC.
  • If warranted, education will be offered to the provider throughout the TPE process. Additionally, at the end of each "round," Noridian will provide notification in writing of findings of claim results and education on potential errors identified. Providers with high error rates will receive an offer for one-on-one education related to the specific errors identified. The goal for providers is to learn from education and improve their results in the next "round" to a low error category.
  • Providers will be moved to another review "round" if error rates remain at a high level.
  • Once a provider has reached an acceptable rate, the provider will be removed from review. Discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.
  • Noridian will continue to monitor data on services and providers with discontinued reviews due to acceptable rates.

I share CMS’s hope that the probe and educate program will result in more knowledgeable providers, reduce denials, and limit the number of appeals. Then everyone can agree it is a success.

Other MAC Medical Review updates since last month are listed below.

Medical Review Updates 8/1/2017
MACService DescriptionService CodeDateError/Denial RateStatus
NGS J6 OP Dental Services CPT 41899 Qtr ending June 2017 39% not stated
NGS JK Percutaneous Cardiovascular Procedure without Coronary Artery Stent DRG 250, 251 4/28/2017 1.36% discontinued
NGS JK Septicemia or severe sepsis with mechanical ventilation 96+ hours DRG 870, 871 5/12/2017 2.63% not stated
NGS JK Inpatient hospital with a respiratory failure related diagnosis(es) ICD-10 codes: J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22 7/21/2017   NEW
Palmetto JM Rituximab, 100 mg J9310 7/26/2017 NC - 13.9% SC - 15.4% WV - 23.7% continue
Palmetto JM Infliximab, 10 mg HCPCS J1745 7/26/2017 SC - 49.8% continue
First Coast JN Psychoses 3+ days MS-DRG 885 7/25/2017   NEW
NGS JE Denosumab HCPCS J0897 7/27/2017 19% continue
NGS JE Denosumab HCPCS J0897 7/7/2017 37% continue
NGS JE Denosumab HCPCS J0897 7/14/2017 49% continue
NGS JE Denosumab HCPCS J0897 7/7/2017 23% continue



Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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