The Program Integrity unit of Indiana’s Office of Medicaid Policy and Planning (OMPP) has implemented a new program to reduce costs related to improper payments.
The Targeted Probe Education (TPE) program, designed by the Centers for Medicare and Medicaid Services (CMS), began August 20, 2021. Like the Medicare Targeted Probe and Educate program, OMPP’s TPE is designed to reduce provider burden by reviewing a small number of claims and providing early intervention and education to providers with high levels of denied claims. The program’s goal is to reduce the risk of fraud, waste and abuse.
According to a recent Indiana Health Coverage Programs (IHCP) bulletin, providers will be chosen for the program based on data analysis of common errors, denials, provider billing problems, prior investigations, and audit reviews, revealing who is likely to submit noncompliant claims in the future. Selected providers will then be required to send in medical records for review. Identified errors within the targeted review will not be subject to recoupment during the TPE process, though noncompliance at any point in the process may lead to audits, prepayment reviews, or administrative sanctions.
TPE Process
The TPE process will consist of an initial notification/submission period and review, followed by the potential for two additional rounds. Here’s what to expect.
Notification and Submission
Providers will receive a letter notifying them that they have been chosen for TPE. The letter will explain what documentation is being requested, how to submit the documentation, and any other information required to conduct the targeted review.
First Round of Reviews
Upon receipt of the requested documentation, Program Integrity staff will review the documentation, applicable laws and policies, and coding requirements, then determine the most appropriate way to bill for the services. Providers will receive a letter with the results of the first round of reviews including education on the results.
If the provider passes with an 85 percent or higher accuracy rate, the provider will not go on to the next round and will be removed from TPE. However, if the provider fails to meet an 85 percent or higher accuracy rate, the provider will be given at least a 45-day period to make changes and improve with the education provided.
Second Round of Reviews
If providers do not meet an 85 percent or higher accuracy rate on the first review round, they will be moved to the second round of reviews. Results from the second round of reviews will be communicated to the provider and will include the information from round one.
If the provider passes the second round reviews with an 85 percent or higher accuracy rate, the provider will not go on to the next round and will be removed from TPE. However, if the provider once again fails to meet an 85 percent or higher accuracy rate, the provider will be given at least a 45-day period to make changes and improve with the education provided.
Third Round of Reviews
If providers do not meet an 85 percent or higher accuracy rate on the second review round, they will be moved to the last round of reviews. Results from the third round of reviews will be communicated to the provider and will also include the information from rounds one and two.
After this third round of reviews, if the provider passes with an 85 percent or higher accuracy rate, the provider will be removed from TPE. However, if the provider fails to meet an 85 percent or higher accuracy rate by the third and final round or the provider refused to participate, then the provider may be subject to one or more of the following actions: audits, prepayment reviews, or administrative sanctions.
According to IHCP, providers who successfully complete the TPE program will not be selected for TPE for at least one year. The goal is for providers to learn from education and improve their claim review results in the next round of reviews with no errors or a low error rate classification.
For more information, check out the July 20, 2021, IHCP bulletin BT202159.
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