Targeted Probe and Educate (TPE) audits are used to increase accuracy and provide education in specific regions. Medicare administrative contractors (MACs) use data analysis to identify physicians and suppliers who have high claim error rates or unusual billing practices, as well as items and services that register high national error rates and are a financial risk to Medicare. 

There are several reasons claims can be denied:

• Auto Deny – Requested records not submitted in a timely manner
• Documentation was not received or incomplete, no determination could be made
• Documentation received contains incorrect, incomplete, or illegible patient identification or date of service
• Documentation lacks or contains illegible physician signature
• Documentation contains stamped signature
• Information submitted does not support the medical necessity of the service billed
• Claim billed in error by provider

From Sept. 1, 2021 to March 31, 2022, in a Palmetto GBA probe on Extracapsular Cataract Removal with Insertion conducted in Alabama, Georgia and Tennessee, the overall claim denial rate was 13%. More alarming was that 53% of those failures resulted from records not being submitted in a timely manner. If you receive an audit notice, you must respond within 45 days or you will fail the round.

Physicians may face up to three rounds of review. Each round examines 20 to 40 claims. Then a letter with the results will be mailed and may require a one-to-one review. If you fail the first round, you face a second review. Failure of multiple TPE audits results in additional action, which may include:

• Extrapolation
• Referral to Unified Program Integrity Contractor (UPIC)
• Referral to the Recovery Audit Contractor (RA or RAC)
• 100% prepayment review

Academy tools and resources are available to help you prepare for your next audit. Members have successfully passed TPE audits and shared their experiences. Academy Coding and Reimbursement Manager Matthew Baugh, MHA, COT, OCS, OCSR recently interviewed Julie Lee, JD on this success.  

Academy Solutions

Engage Academy consultation services for chart audits and documentation reviews. 

Ultimate Documentation Compliance Training for Scribes and Technicians is the comprehensive online course that transforms practice staff into a “compliance shield.”

Academy Resources

Find current cataract requirements for your Medicare administrative contractors at www.aao.org/lcds.

Fact Sheet for Documenting the Need for Cataract Surgery

Find additional information about audits at www.aao.org/audits.