Health is wealth – this is especially true in the United States, where healthcare costs are one of the most expensive in the world. More often than not, staggering medical costs drive people into poverty. That is why health insurance programs like Medicare have been established to protect people from taking on such huge financial risks. Medicare, however, is in the same position – it would like to protect itself from fraudulent claims which could affect its ability to provide insurance coverage to those who are eligible and deserving. As such, medical reviews were developed to identify and evaluate the validity of Medicare claims. One such review is the Targeted Probe and Educate or TPE, and closely linked to it is the ADR or Additional Document Request. If you’re wondering what these two Medicare terms are and how they matter to you, here are the things you should know.
Targeted Probe and Educate (TPE)
TPE is an audit or review program conducted by your Medicare Administrative Contractor (MAC) to aid you in reducing your claim denials and appeals through one-on-one education sessions. It intends to increase your accuracy in areas where you currently have high claim errors, thus decreasing your denial and appeal rates. In addition, you can be selected if your MAC identifies you as posing a high financial risk to Medicare, getting higher claim denial rates than others, or having unique billing practices.
If you get selected to be part of a TPE, you will receive a formal written notification from your MAC. Your MAC will then review around 20 to 40 of your claims and supporting documents. CMS identified this as the appropriate sample size to accurately assess the level at which providers ensure their records meet Medicare requirements. Should several of your claims be denied, there will be a one-on-one education session between you and your MAC which can be held via a webinar or teleconference.
During the session, your MAC will walk you through the identified errors and provide insights into how to avoid similar errors in future submissions. You may also ask questions regarding any CMS policy that applies to your reviewed claims. After which, there will be a 45-day deadline for you to improve and comply with the requirements. If you are compliant, you can rest easy as there will not be another audit on the same topic for at least a year.
On the contrary, if you are found to be non-compliant, you will be subjected to another round of review with a maximum of three rounds. If after three rounds of review and education sessions you still failed to improve, you will be endorsed to CMS for further action. These may involve a full prepayment review, a referral to a Recovery Auditor, or extrapolating events you should avoid as much as possible.
Additional Document Request (ADR)
On the other hand, an ADR is a request for medical records or documents generated when a particular claim is selected for a medical review, such as a TPE. It can also be raised when a requestor determines that additional documentation is necessary to complete a claim. Requestors may be Recovery Audit Contractors, Supplemental Medical Review Contractors, or any other Medicare contractor.
The ADR letter reflects the deadline by which you must submit your response. It is vital that you comply with the stated timeline since not responding will result in partial or total claim denials, which means insufficient or zero reimbursements for your agency. Any claim submitted to Medicare may be subjected to an ADR. However, a claim is more likely to be selected if its elements match the audit or review parameters.
In addition, the ADR letter usually contains the list of items billed on the claim you submitted and the corresponding documentation necessary to validate that these items comply with Medicare regulations. The letter also reflects options for submitting the documents to the requestor. Before responding to an ADR letter, your agency must understand what records are requested and when they should be submitted. Make sure you submit the complete set of documents in one response to the correct requestor, as identified in the letter. For multiple claims subject to an ADR, send separate responses for each claim for proper monitoring. Use the ADR letter as the cover sheet to your response and only submit clear copies of the requested documents as Medicare contractors are not obliged to return submitted papers.
Make sure to always be in the loop of the latest policies regarding TPEs and ADRs. Join us on April 21-22, 2022, at the Marriott in Monrovia, California, for a two-day live conference brought to you by Data Soft Logic and the National Government Services. We will cover topics on home health and hospice billings, top billing errors, common reasons for denials and how to avoid them, and many more. Check, like, and follow DSL’s Facebook and LinkedIn pages for further details on this webinar and click here to register.
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