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Medicare Overhauling the Fraud Audit Process

The Centers for Medicare & Medicaid Services (CMS) announced changes to the way it audits claims for fraud, by selecting claims that pose the greatest financial risk.

The agency’s current “Probe and Educate” strategy for claims review will move to a more streamlined Targeted Probe and Educate (TPE) approach. TPE will involve the review of fewer charts per provider, with a range of 20-40 claims, followed by one-on-one, provider-specific education to address any errors that are found. Providers with high error rates after the first round will be subjected to second reviews of an equal number of charts and additional education, followed by third and fourth reviews if necessary. If error rates continue the provider may be referred for other action, including recovery of money by extrapolation, or other actions. If providers reduce error rates, they may be removed from the TPE program.

The Medicare Administrative Contractors (MACs) will identify providers for TEP who have the highest claim error rates, or billing practices that vary significantly from their peers.

Currently, MACs choose claims for review based on factors such as improper payment rates, data analysis, and certain billing patterns. This has led to burdensome targeting of providers, and to a backlog of claims reviews that CMS is currently working to verify.

This change in policy should relieve providers who have compliant claims submissions that do not vary significantly from other providers of the threat of audit.