Even though Medicare TPE audits are performed by a healthcare provider’s Medicare Administrative Contractor (MAC), rather than by law enforcement, that does not mean that they can be taken lightly. The consequences of failing an audit are severe. Providers may have to go through prepayment review of all future Medicare claims. In extreme cases, they can lose their access to the Medicare program and can even be referred to law enforcement for further action, up to and including a Medicare fraud investigation.
Having healthcare audit lawyers on hand to guide you and your medical business through the process can drastically improve the outcome. Even if you have not been audited, yet, hiring a lawyer to craft an effective compliance protocol or to conduct an internal review of your billing procedures can prevent problems or uncover them before they become an issue.
A Targeted Probe and Educate (TPE) audit is a close review of a healthcare provider’s billing practices for Medicare claims. The goal of the audit is to uncover mistakes in the provider’s bills, like differences between the services that were provided to the Medicare patient and what was reflected on the bill sent to the Medicare Administrative Contractor (MAC). If problems are found, the MAC will work with the healthcare provider to correct the mistakes and to help the provider avoid making them in the future.
While it is the MAC that performs the TPE audit, the Centers for Medicare and Medicaid Services (CMS) encourages them. In the eyes of the CMS, TPE audits serve as an important way to keep the Medicare program efficient. That was why the CMS created the TPE audit pilot program in 2017 and expanded it drastically in the years since.
The stated goal of TPE audits is educational: If mistakes are uncovered in the audit, the MAC will provide a one-on-one education course with the provider to walk them through the errors, explain how to fix them, and show the provider how to avoid making them, again.
However, TPE audits carry the potential for serious sanctions if the MAC is not satisfied with the healthcare provider’s progress. The MAC can choose to closely scrutinize all further Medicare requests and can even refer the provider to the CMS for further action.
The TPE Audit Process
MACs generally choose to audit healthcare providers based on an analysis of the provider’s Medicare claims. Providers who have a high rate of denials or who use certain billing codes far more than their peers are more likely to get audited by their MAC.
When a MAC decides to conduct a TPE audit on a provider, it will send a Notice of Review letter. This letter initiates the TPE audit, states the reason why the MAC has chosen the provider for the audit, and requests supporting records for a sampling of 20 to 40 Medicare claims.
The size of this sampling is designed to give MACs enough data to be representative of the provider’s billing practices, while still not being overly burdensome to the provider.
Once the records have been received, the MAC will compare the Medicare claims against their supporting medical records. The TPE audit looks for errors like:
- Missing or incomplete certifications or proof of recertification
- Documentation that does not support the medical necessity for what was billed
- Encounter notes that do not support medical necessity or all of the elements of Medicare eligibility
- Records that do not have the certifying physician’s signature
- Incorrect coding for a medical procedure or service
If the MAC is satisfied, it will end the TPE audit. Once audited, the provider cannot be selected for another TPE audit for at least a year, unless the MAC sees a significant change in the provider’s billing practices.
If the MAC is not satisfied, the MAC’s outreach and education staff will schedule a one-on-one session with the provider to walk them through the errors and explain how to correct and avoid them. After this session, the provider has 45 days to make the appropriate changes. The MAC can then request supporting documentation for a second round of 20 to 40 Medicare claims. The dates of service for this new sampling have to be at least 45 days prior to the completed education session.
If the MAC is not still satisfied by the provider’s improvement, it can order a third and final round in the TPE audit. If it is still not satisfied, the MAC can fail the provider and refer it to CMS for further action.
Providers can appeal the outcome of a TPE audit through the Medicare appeals process.
The Penalties for Failing an Audit are High
If the MAC is dissatisfied with the healthcare provider’s progress after three rounds of review, the MAC will refer the provider to the CMS for disciplinary action. The CMS has wide discretion in issuing sanctions for a failed TPE audit, though common penalties have included:
- Referring the provider to a Recovery Audit Contractor (RAC) or a Zone Program Integrity Contractor (ZPIC)
- Extrapolating overpayments from the samples
- Requiring prepayment reviews of all further Medicare claims
- Suspension of Medicare payments
- Exclusion from the Medicare program
These penalties can cripple a healthcare provider’s ability to handle Medicare patients. Worse, it can open the provider up to the potential for civil or even criminal liability if a subsequent investigation uncovers Medicare fraud.
Keys for Passing a TPE Audit
The best way to pass a TPE audit successfully and effortlessly is to have a strict code of compliance in place that keeps billing errors to a minimum. That code should remind doctors and administrators of what they have to do in the course of their daily work to help the institution pass a TPE audit with flying colors.
Even if a code of compliance is in place, though, it can still be wise to hire a healthcare lawyer to conduct an internal review once the provider learns of the audit. This review can uncover potential problems before the audit does, giving the provider time to correct them before they can cause an audit failure or an extra round of review. Even better, hiring outside counsel to conduct an independent audit when no TPE audit is pending can better prepare the provider for the inevitable Notice of Review letter from their MAC.
Hiring an attorney for the audit can also ensure that the healthcare organization provides all of the necessary documentation on time. Each MAC has its own TPE audit procedure, and the details of the process matter. Failure to timely response can be flagged as an error in the audit and could lead to a failure.
Frequently Asked Questions
Are TPE Audits Still on Hold Due to COVID?
No. The Centers for Medicare and Medicaid Services (CMS) put TPE audits on hold in the early days of the coronavirus pandemic in an attempt to lighten the regulatory load on healthcare providers who were swamped with patients in dire need of care. However, these audits have resumed, starting on September 1, 2021.
How Many TPE Audits are Conducted in a Year?
According to the Centers for Medicare and Medicaid Services (CMS), Medicare Administrative Contractors (MACs) in the U.S. performed around 13,500 TPE audits on healthcare providers and suppliers between October 2018 and September 2019. These audits reviewed around 435,000 claims against Medicare during that period. The CMS estimates that there were approximately 90,000 educational contacts during and after TPE audits during that time. These contacts included letters, phone calls, emails, and face-to-face sessions, in addition to the webinar views that are the focus of the education sessions in the audit process.
How Often Do Providers Fail a TPE Audit?
The Centers for Medicare and Medicaid Services (CMS) estimates that, of the 13,500 providers who were audited by the TPE program between October 2018 and September 2019, less than two percent of them failed all three rounds of the examination.
These healthcare providers have the option of appealing the results of the TPE audit. These appeals go through the standard Medicare appeals process. Hiring a Medicare lawyer to help make an effective appeal is essential.
Why Doesn’t Oberheiden, P.C. Call Itself the Best TPE Audit Law Firm?
Oberheiden, P.C. prefers to let the experience of its attorneys and the track record of the results that they get for their clients do the talking for them. We have helped numerous healthcare providers navigate the TPE audit process, and have created effective compliance codes for many more. In both of these roles, our legal representation has protected the institution and its workers from legal liability, be it civil or criminal.
Our attorneys get these results in large part because of their extensive experience in the field of healthcare law and the complicated subfield of Medicare compliance. Many of our lawyers were prosecutors and investigators before joining Oberheiden, P.C., and had a long history of prosecuting healthcare and Medicare fraud. That experience gives them the insider information that they need to get ahead of investigations by law enforcement in order to better protect their clients. It also helps them understand how the outcome of an audit can impact a particular healthcare provider in the future.
Healthcare Lawyers at Oberheiden, P.C. Can Help
Whether you have received a Notice of Review letter from your MAC or want to prepare for when it comes, the healthcare lawyers at Oberheiden, P.C. can help. Call them at 888-680-1745 or contact them online to get started.