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More Focused CMS Audits Will Reduce Burden on Accurate Claims Processors


In an effort to reduce the burden on those claims processors who submit claims correctly, the Centers for Medicare and Medicaid Services (CMS) recently announced that it will target those providers and suppliers that have high error rates.

CMS is directing its Medicare Administrative Contractors to focus medical reviews on specific providers and suppliers within a service, instead of all providers and suppliers that are billing a particular service.

New Audit Process Targets Those with High Claim Error Rates

The new Targeted Probe and Educate pilot will select claims for services and items that present the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate.

Under the prior process, the first round of reviews included all providers who deliver a specific service. The new changed claim selection procedure is more provider- and supplier-specific, and those who are already submitting compliant claims will have a reduced audit risk.

After 3 rounds of review, providers and suppliers that continue to have high error rates may be subject to additional actions. These can include 100% prepay review or referral to a recovery auditor. After demonstrating sufficient improvement or low error rates, the targeted providers and suppliers may be removed from the review process.

The original Targeted Probe and Educate program was launched by CMS in 2014 in an effort help reduce errors in the claims submission process. So far, CMS acknowledges that the program is a success due to the decrease in the number of claim errors after providers receive education and guidance.

You can read more about Targeted Probe and Educate medical reviews here.

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