Medicare introduces new claim review process

Medicare is always working to fight fraud and abuse. With that, a new type of claim review has recently begun: a process called Targeted Probe and Educate, or ‘TPE’ for short.

How TPE works:

Palmetto GBA/Railroad Medicare will conduct data analysis and find providers whose billing may be very different from their peers. Palmetto will also look at providers who have been identified as having a high error rate (having filed claims that should not be paid, due to medical necessity issues, billing or coding errors, or ones that do not have sufficient documentation to support the service was rendered as billed).
Once a provider is identified, Palmetto will request records for 20 to 40 services, depending on how much the provider has billed to Railroad Medicare.
After the claims are reviewed, one of Palmetto’s clinical staff members will contact the provider by letter and by phone to go over their results and offer education on how to bill and document their services correctly. If the provider has a high error rate in the review, then Palmetto will ask for records for an additional 20-40 claims submitted for payment and follow the process outlined above. If the provider fails to improve again, then a last round of TPE is conducted. If the provider’s error rate is still unacceptable, they will be referred to Palmetto’s Benefit Integrity Unit for investigation. The same is true for providers who refuse to respond to the records requests.
However, if the provider makes an appropriate improvement, they can be removed from the TPE process for a period of time, and then rechecked later to be sure they are still in compliance.

If your provider has questions:

Your provider may have questions about this review process. If they do, please ask them to call our Provider Contact Center at 888-355-9165 and select Option 5. Customer Service Representatives can assist them in understanding the TPE process. All Medicare contractors are using the TPE process to review claims.
If you have any questions about your Railroad Medicare coverage, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877-566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.
Palmetto also invites you to join their listserv/email updates. Just select the ‘Listservs’ link at the top of their main webpage at www.PalmettoGBA.com/RR/Me.