CMS is taking the training wheels off the targeted probe and educate (TPE) progam pilot that it rolled out in May and expanded in June. Effective Oct. 1, your Medicare administrative contractor (MAC) will begin to phase out most forms of medical review and replace them with TPE.
According Change Request 10249 for CMS 100-20:
The MAC shall phase out all medical record reviews, including all service-specific reviews, other than reviews conducted as part of the Targeted Probe & Educate program or as otherwise directed by CMS.
Automated medical reviews are excluded from the phase-out, CMS notes in the change request. And the change doesn't mean practices can ignore any requests for documentation -- aka additional development requests -- they have received from their MACs. CMS has instructed MACs to finish up any pending medical reviews as they make the switch.
Your MAC will use the improper payment reduction strategy "data analysis,and CMS instruction to determine the targeted items, services, devices and/or providers" that will be subject to TPE. The good news is this will likely mean fewer providers will be subject to medical reviews. The bad news is the stakes are higher for those who are targeted.
If high denial rates continue after three rounds, the MAC shall refer to CMS for additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the RAC, 100% pre-pay review, etc.
Providers who were targeted and improved could remain on their MAC's radar for up to a year. According to the change request, the MAC will continue to monitor who had "identified risk" during the probe portion of the review.