Everything You Need To Know About New Prepayment Audits

New prepayment audits strike fear in Medicare providers. Many medical practices accept patients who are covered by Medicare or Medicaid. If you’re one of these practices, you need to know about some updates in these agencies’ auditing processes that can seriously affect your patients and your medical practice. 

In 2017, the Centers for Medicare & Medicaid Services announced that they would be implementing a new method of auditing called Targeted Probe and Educate (TPE). This program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.

This new system is sometimes withholding pre-payment reimbursements for months at a time until the audit is complete. Find out all about the new prepayment audits process so you can best prepare your business and your patients.

What Is TPE?

This nationwide audit program covers all Medicare providers. The process of selection for this program is based on claims for items and services that have a high national error rate and/or pose the greatest financial risk to the Medicare trust fund.

Once a practice is selected, it will have to submit about 20 to 40 claims for a one-on-one review by a Medicare Administrative Contractor (MAC). If the provider is found to have high error rates, further auditing will include another round of probe reviews and education. MACs are allowed three rounds of audits before referral back for next steps of completing the pre-pay review.

What This Means for Practices?

Both solo physician practices and large group practices are susceptible to the ever-increasing audits. The CMS has requested that the MACs focus on providers with billing practices that diverge significantly from their peers. Mainly, the TPE system is making efforts toward uniformity and accuracy in the medical field with each appointment and each medical session.

The “E” in TPE stands for Educate, and this is one of the main principles of the process.

For example, auditors may make suggestions for improving the running of a practice. Some of these suggestions may be in qualifying medical necessity of items or services, making treatment plans more specific, and mentioning measurable symptoms and behaviors. They also like to see connections between previous visit goals and the present situation.

While these audits are not completely unavoidable, you can review the billing and procedure practices of your business ahead of time by visiting the CMS website to ensure you’re “up to code” with their provider regulations.

Most providers will never need TPE

TPE is intended to increase accuracy in very specific areas.
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.

Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.

What are some common claim errors?

1. The signature of the certifying physician was not included.
2. Documentation doesn’t meet medical necessity.
3. Encounter notes didn’t support all elements of eligibility.
4. Missing or incomplete initial certifications or notification.

How does it work?

At WWS our experts will know how your billing practices should be handled in order to help avoid being audited.

To learn how we can take the burden off handling your billing functions while helping you pinpoint financial opportunities to drive your practice revenues, call us today at +1(302) 613-1356.