Presented by Nexsen Pruet's Stephen Bittinger

1. Are Hospital Physician
Networks Ready for TPE
Audits?
Stephen Bittinger
Healthcare Reimbursement Attorney
NEXSEN PRUET, LLC

2. Goals for Today
(Executive Summary)
Learn the Scope, Process, and Risks of a Targeted
Probe and Educate (TPE) Audit
How TPEs are becoming more risk that education.
Learn the Appeals Processes and Legal Options for
Defending TPEs
How and why to appeal TPE findings
What Services Are Targeted
Palmetto GBA’s current TPE work list

3. CMS Targeted Probe and
Educate (TPE) Audits
 Medicare Administrative Contractors (MACs) perform TPE audits
 Providers are targeted for TPE based on:
 Questionable billing practices
 Claim error rates from prior reviews
 Services that have high national error rates
 Services that are at financial risk to Medicare
 Most common claim errors:
 Missing signatures
 Documentation does not establish medical necessity
 Encounter notes lack support for all elements of eligibility
 Missing or incomplete initial certifications or re-certifications for
services

4. CMS Targeted Probe and
Educate (TPE) Audits
 Steps in the TPE process:
 Targeted providers will receive a letter from MAC requesting
documentation for 20-40 claims;
 MAC will review the documentation to determine if there are errors and
recoupment should be made;
 Providers with denied claims will have one-on-one education session;
 Providers will have 45 days to make changes and improve (established
by another production and review);
 Providers that achieve 100% compliance will not be reviewed for
another year; and
 Providers that fail to achieve 100% in three reviews in less than 1 years
will be referred to CMS for options below.

5. CMS Targeted Probe and
Educate (TPE) Audits
 Potential consequences of failing three reviews:
 Recoupment of all denied claims during the course of the TPE;
 100% prepayment review of all claims;
 MAC can extrapolate error rate from sample over universe of claims
(back 6 years) and make overpayment demand on them all;
 Referral to RAC for same extrapolation process;
 Referral to UPIC for fraud and abuse investigation;
 CMS can begin Medicare exclusion process; and/or
 CMS can refer the provider to the Office of Inspector General (OIG) for
potential criminal prosecution for billing fraud by the DOJ.

6. Medicare Appeals Process
 Five Levels of Appeal:
 1. Redetermination (MAC) – 120 days for timely, but 30 days to
stop recoupment; MAC decision within 60 days
 2. Reconsideration (Qualified Independent Contractor – QIC) –
180 days for timely, but 30 days to stop recoupment; QIC
decision within 60 days, but cannot stop recoupment after this 3.
Office of Medicare Hearings and Appeals
(OMHA)/Administrative Law Judge (ALJ) – 60 days for timely,
but currently on a 1,300+ day wait for ALJ hearing (Injunctive
Relief?) (Escalation to Medicare Appeals Council)
 4. Medicare Appeals Counsel (MAC)/Department of Appeals
Board (DAB) – 60 days for timely, 90-180 days for decision
 5. Federal District Court – 60 days for timely, but limited review

7. Medicare Appeals Process
 Reality of CMS Appeals
 ALJ Backlog – it is a nightmare that is hopefully dwindling
 Appeal to hold off recoupement; timing is everything
 First level of appeal can point out MAC’s error in TPE denials.
 QIC level has a higher overturn rate.
 ALJ is the first genuine, objective review level for overturning
denials.
 Medical Appeals Counsel frequently overturns ALJ decisions.
 Federal District Court has limited review.
 Whether to Appeal
 Only cost effective appeals
 Special service or unique provider appeals

8. Palmetto GBA’s TPE Work List
• Part A Focus:
• Major joint replacement or reattachment of lower
extremity without major complication or comorbidity,
Psychoses, ultra-high RUG codes, hyperbaric oxygen
therapy (HBOT), Pegfilgrastim, Rituximab 100mg,
Infliximab 10mg, Bevacizumab 10mg, Denosumab
1mg, heart failure & shock with MCC and health
failure & shock with CC

9. Palmetto GBA’s TPE Work List
• Part B Focus:
• Evaluation and management
• Subsequent hospital inpatient care (35 minutes per day)
• Emergency room
• Critical care
• First hour plus
• Therapeutic exercise

10. Palmetto GBA’s TPE Work List
• Home Health & Hospice Focus:
• Eligibility
• Medical Necessity

11. Summary
 TPE audits are proving to have far more risk
than education
 The most effective defense is properly handling
the TPE process to ensure compliance within
one year
 Appealing denials should be determined on a
case-by-case basis
 Prepare your targeted providers

12. Stephen Bittinger, Esq.
www.nexsenpruet.com
sbittinger@nexsenpruet.com
(o) 843-720-1703
(c) 440-823-0664