Centers for Medicare and Medicaid Services Announces Transition to Targeted Probe and Educate Strategy

In August, 2017, the Centers for Medicare & Medicaid Services (“CMS”) announced a major change in how it will approach the selection of Medicare claims for improper payment review.

In particular, CMS intends to move from its broad Probe and Educate strategy to a new Targeted Probe and Educate strategy (“TPE”). For purposes of both strategies, CMS utilizes Medicare Administrative Contractors (“MACs”) who review clinical documentation in order to prevent improper payments. Under the broad Probe and Educate strategy, MACs chose claims for review based on factors such as the service specific improper payment rate, data analysis, and billing patterns of providers/suppliers. Under TPE, however, the selection of claims to review will become a two-step process: MACs will first identify claims for items/services that present the greatest financial risk or that have a high national error rate and will then, in turn, focus within that item/service on providers/suppliers who have the highest claim error rates or whose billing practices vary significantly from their peers. According to CMS, TPE will involve the review of 20-40 claims per provider, per item or service, per round, with each round of 20-40 claim reviews being a probe. After each probe, providers will be offered education which will be individualized based on the outcome of the probe. Providers/suppliers with moderate to high error rates in a probe will continue on through another probe, followed by additional, individualized education, for a total of up to three probes. In order to help suppliers/providers avoid repeated or similar errors, MACs will educate providers throughout the review process, in addition to providing the individualized education at the end of each probe.

Providers/suppliers who continue to have high error rates after the three probes may be referred to CMS for additional action. Alternatively, providers/suppliers who demonstrate low error rates or sufficient improvement in error rates may be removed from the review process after any probe.

Overall, this change will result in a lessened burden on providers/suppliers who are already submitting policy compliant claims and will result in a comparatively smaller number of claims being reviewed.


Prepared by:
Denay Brown, Esq.
[email protected]
P. 850.222.0720