Railroad Medicare and the Targeted Probe and Educate Process

Published 08/31/2021

Tarteted Probe and Educate (TPE) is a medical review process that focuses on provider-specific review of claims and provides education to providers billing these claims. Palmetto GBA Railroad Medicare will conduct data analysis and identify claim types with the greatest risk of inappropriate program payment. 

TPE has resumed September 1, 2021. On August 24, 2021, we mailed letters to those providers whose TPE cases were paused due to the PHE to alert them that their pre-PHE TPE cases would be closed. New data analytics will be performed to restart the TPE program. 

Palmetto GBA Railroad Medicare will be conducting TPE pre-payment and postpayment reviews. Refer to the Targeted Probe and Educate Planned Reviews article for the list of services under TPE review. 
 

Starting TPE

Palmetto GBA Railroad Medicare selects providers for the TPE process based on the following: 

  • Analysis of billing data indicating aberrancies that may suggest questionable billing practices 
  • Previous error rate results of targeted review 
  • Service-specific review error rate results 

Once a provider is selected for review, Palmetto GBA Railroad Medicare will mail a TPE notification letter which outlines the reason for selection and provides an overview of the TPE process and contact information. Providers with active eServices accounts will receive TPE notification letters via greenmail in their eServices inboxes.


TPE Overview

  • TPE consists of up to three rounds of review with 20–40 claims sample selected (pre-payment or postpayment) for each round 
  • Subsequent rounds will begin 45–56 days after individual provider education is completed. Discontinuation of review may occur if appropriate improvement and compliance is achieved during the review process.
  • Prior to the conclusion of each round, a medical reviewer will call providers with moderate to high error rates to discuss the summary of the errors found through the TPE process


TPE Requests for Records

An Additional Document Request (ADR) letter will be generated for each claim selected in a TPE round. Providers with active eServices accounts will receive TPE ADR letters via greenmail in their eServices inboxes. This letter will include a list of specific elements needed to support the service on review. 

  • For pre-pay reviews, Palmetto GBA has 30 days from the date the documentation is received to review the documentation to make a payment decision
  • For postpay reviews, Palmetto GBA has 60 days from the date the documentation is received to review the documentation to make a payment decision


Responding to a TPE Records Request

It is important to respond to a TPE ADR promptly with the requested documentation within 45 days to avoid a non-response denial. Non-response denials count as an error when calculating the error rate. 

Palmetto GBA Railroad Medicare recommends you use eServices, our secure online web portal, to submit documentation in response to medical review ADRs. You may also use eServices to respond to requests for additional documentation throughout the TPE review process. If you are not already registered to use eServices, visit the portal for more information. Please see the eServices User Manual (PDF, 6.05 MB) for instructions on registering for and using the portal.

Other methods to respond to an ADR include: 

  • By Fax to (803) 264–8832 
  • Via the esMD (Electronic Submission of Medical Documentation) mechanism. For more information about esMD, please see the CMS website.
  • By mail to: 

Palmetto GBA Railroad Medicare
ATTN: Medical Review 
PO Box 10066
Augusta, GA 30999


Requesting Additional Time to Respond

Medicare contractors have the discretion to grant an extension to providers who need more time to comply with the medical record request. If you are unable to reply within the required timeframe, please submit an extension request to Palmetto GBA using your preferred submission method. Please be aware that this instruction is specific to restarting TPE and is intended to be temporary in nature; the ability to request an extension will coincide with the COVID 19 Public Health Emergency. 

Please include the required information with your extension request, addressed to MR ADR Extension Request:

  • The identifying claim information (date of service, claim number, beneficiary name/MBI)
  • The identifying provider information (provider number, provider name and name of requestor)

In addition to the submission methods listed above, you may also reach out to the Provider Contact Center at 888–355–9165 for assistance.


TPE Results

At the conclusion of each round, you will receive a letter with the review results. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part.

When high denial rates continue after three rounds of TPE, Palmetto GBA Railroad Medicare will send the case for further investigation.


Non-TPE Reviews

Palmetto GBA Railroad Medicare will continue to conduct service-specific pre-pay and postpayment reviews of claims for providers not under TPE review. These reviews focus on providers who do not meet the TPE claim volume threshold. Conducting these additional reviews is another way Palmetto GBA/Railroad Medicare seeks to reduce the claims payment error rate. We will post a listing of the non-TPE pre-payment and postpayment claim review topics on our Medical Review Notifications page. 


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