At 1ˢᵗ Credentialing we know that when our clients place their trust in us, we take that responsibility seriously by communicating with our clients to create a transparent and collaborative partnership.
Healthcare organizations of every size realize that hiring 1ˢᵗ Credentialing is the most economical and efficient way to solve their credentialing needs. We have the training, expertise and commitment it takes to keep a complex process moving forward at all times.
1ˢᵗ Credentialing supports healthcare practices of all sizes - from health systems, to community hospitals, to large group practices, to smaller organizations. We help get your providers up and practicing as fast as possible.
Learning more about the credentialing process benefits us and our clients. 1ˢᵗ Credentialing offers regular videos and newsletter updates to bring our clients and those interested in innovations in credentialing up to speed.
Are You in Line for a Medicare Targeted Probe and Education Audit?
It’s known as a TPE review. Have you heard of it? A Centers for Medicare & Medicaid Services (CMS) Targeted Probe and Education audit is a periodic review with the goal of reducing claim denials and appeals by providing claim review along with one-on-one provider education.
This is no trivial review. If the provider does not show compliance at the end of the review process, the consequences may be serious and may even include revocation of Medicare billing privileges.
What Is Involved in a TPE Review?
A Medicare Administrative Contractor (MAC) conducts the TPE review and has wide discretion on its process.
Healthcare providers and suppliers are selected for the audit based on data analysis, targeting those providers and suppliers with high denial rates or with claims activity that appears unusual when compared to peers. The review usually focuses on a claim prepayment basis, although post-payment audits are also considered. Generally, 20-40 claims are sampled.
Some of the claim errors that may trigger a TPE audit include:
If, based on the TPE review, the provider or supplier is regarded as compliant, they will not be reviewed on that particular basis for at least one year. However, when the MAC finds noncompliance, another round of review is required preceded by one-on-one education sessions.
Education Is a Major Goal of TPE Audits
CMS requires that education is a major focus of both the claims review process and post-review. The one-on-one education sessions may be face to face or via the telephone or webinar.
After the one-on-one counseling, the provider or supplier has at least 45 days to correct any errors before the next round of claims review. After three rounds of education, the provider will be referred to CMS for further action.
Potential negative outcomes of a TPE audit include revocation of billing privileges if there is a pattern of submitting sub-standard claims; removal from participating in Medicare; fraud investigation.
Providers and suppliers must comply with Medicare requirements in submitting documentation on a timely basis and keeping supporting records to demonstrate compliance.
Let Us Manage All Your Payer Enrollment Services
If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson, our company owner and President, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website.
Our credentialing experts are here to help you assess exactly which solutions you need and let you know how inexpensively we could put you on the right track. 1ˢᵗ Credentialing includes primary source verification and payor enrollment for all insurance networks including Medicare, Medicaid, Medi-Cal and insurance networks. Don’t wait another minute, contact our terrific team today!