Failing a TPE audit can result in onerous actions.
Healthcare audits have now resumed to 100-percent capacity – or even 150 percent. All audits that were suspended during COVID have been reinstated.
As you all know, Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) audits were reinstated back in August. The Centers for Medicare & Medicaid Services (CMS) then announced that Targeted Probe-and-Educate (TPE) audits would resume on Sept. 1. Unlike RAC audits, the stated goal of TPE audits is to help providers reduce claim denials and appeals with one-on-one education, focused on the documentation and coding of the services they provide. However, do not let that fool you. Failing a TPE audit can result in onerous actions such as 100-percent prepay review, extrapolation, referral to a RAC, or other remediation, so a carefully crafted response to a TPE audit is critical. TPEs can be prepay or post-pay.
Speaking of prepayments, these too are back in full swing. CareSource is one of the companies contracted with CMS to conduct prepayment reviews, and urgent care centers seem to be a target. Prepayment review is technically and legally not a penalty; therefore, being placed on prepayment review is not appealable. But do not put too much stock in that – prepay is draconian in nature and puts many providers out of business, especially if they fail to seek legal counsel immediately, believing that they will pass without any problem. When it comes to prepayments, believing that everything will be OK, is a death trap. Instead, get a big stick.
42 CFR §447.45 requires 90 percent of clean claims to be paid to a provider within 30 days of receipt. Ninety-nine percent must be paid within 90 days. The same regulations mandate that each agency conduct prepayment review of claims to ensure that the claims are not duplicative, that the consumer is eligible for Medicare, and/or that the number of visits and services delivered are logically consistent with the beneficiary’s characteristics and circumstances, such as type of illness, age, sex, and service location. This standard prepayment review is dissimilar from a true prepayment review.
Chapter 3 of the Medicare Program Integrity Manual lays out the rules for a prepayment review audit. The Manual states that MACs shall deal with serious problems using the most substantial administrative actions available, such as 100-percent prepayment review of claims. Minor or isolated inappropriate billing shall be remediated through provider notification or feedback, with reevaluation after notification. The new prepay review rules comments closed on Sept. 13, so they will take effect soon.
If a 100-percent prepay is considered the most substantial administrative action, then why is it not considered an appealable sanction? I have, however, been successful in obtaining an injunction enjoining the suspension of payments without appealing being placed on prepay.
When requesting documentation for prepayment review, the MACs and Unified Program Integrity Contractors (UPICs) shall notify providers when they expect documentation to be received. It is normally 30 days. The Manual does not allow for extensions to providers who need more time to comply. Reviewers shall deny claims when the requested documentation to support payment is not received by the expected timeframe.
Any audit, but especially prepay audits, can lead to termination under 42 CFR §424.535.
Remember, you may choose to speak softly, but always carry a big stick.
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In the ever-evolving world of Medicare audits, 2025 is shaping up to be a year of Alice’s Wonderland. Enter stage right: artificial intelligence (AI), a
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