CMS under its Medical Review Policy holds its contractors such as the Medicare Administrative Contractors responsible for insuring the payment of provider claims accurately with the primary mission of reducing provider billing errors. The primary goal is to pay the claims correctly the first time around. MACs review clinical documentation to prevent improper payments and choose claims for review based on many factors such as the service specific improper payment rate, data analysis and billing patterns of the provider.
In 2014 CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy, Probe and Educate. Rather than focus upon all providers using a “widespread” approach to medical review, CMS is now further improving this strategy by moving from a broad Probe and Educate program to a more targeted one (Targeted Probe and Educate) by focusing upon providers with aberrant coding and billing patterns. The MACs identify providers with potential billing patterns through advanced data analytics and data mining from historic claims. Under the TPE program, MACs will select claims for services that pose the greatest financial risk to the Medicare Trust fund and/or those that have a high national error rate. Within these identified areas, the MACs will identify and focus upon review of claims from providers with the highest claims error rates or billing practices that significantly out from their peers. Let’s look and closely exam