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David McGill Blogger

Region D Releases TPE Results

Posted by David McGill | May 01, 2018

Noridian, the DME MAC for Region D, released the AFO/KAFO Targeted Probe and Educate Review results for the 4th ​quarter of 2017. Here's what you need to know:

  1. Noridian reports that the potential improper payment rate resulting from the TPE Review is 19%. (While this is not the same as the claim error rate, historically, improper payment rates and claim error rates tend to correlate somewhat closely, so we can reasonably assume that roughly 19-20% of the claims reviewed as part of the TPE program failed to satisfy the stated requirements.)

  2. The top listed reasons for denials were (a) incomplete/missing Detailed Written Order, (b) failure of the author to authenticate medical record documentation, (c) claim was the same or similar to another one already on file for the patient, and (d) documentation did not include verification that the AFO/KAFO was lost, stolen or irreparably damaged in a specific incident.

What does this mean for you?

First, as we have written about previously, TPE is a new type of review program initiated by the DME MACs. The TPE process can consist of up to three rounds of claims reviews. For the reasons outlined below, it is essential that you have a high enough pass rate to exit the TPE program by the completion of Round 3.

TPE Process Diagram

If you get selected for TPE, the MAC will assign a reviewer to your company. This individual will request documentation - typically 20-40 claims - from you and let you know in real time whether the claim meets or fails to meet Medicare's coverage requirements. If your failure rate is too high after the first round of reviews, the MAC will continue with a second round. If, after three rounds of reviews your error rate remains unacceptably high, the MAC will refer you to Medicare for next steps, which can include 100% prepayment claim review, referral to a Recovery Auditor, or extrapolation (e.g., if your failure rate after 3 rounds was 50%, extrapolation would involve clawing back 50% of all payments previously made by Medicare for claims involving the examined codes during a specified time period).

Second, the most common reasons for denied claims listed by Noridian are all basic documentation requirements. It is important to remember that the criteria you need to satisfy can appear in one of three different DME MAC documents: the Local Coverage Determination; the Policy Article; or the Standard Documentation Requirements. You should go to Noridian's website (if you are in Regions A or D) or CGS's website (if you are in Regions B or C) to access and review these documents. 

Finally, the potential improper payment rate for AFO's and KAFO's of 19% is substantially lower than Noridian's historical prepayment claims review data, which from 2013-2017 showed claim failure rates of 66% to 100% in Region D depending on the AFO/KAFO codes at issue. We do not have a good understanding at this time of why the TPE data looks so different from the prepayment claims review results. Our best guess is that the nature of the TPE process itself, with multiple rounds of education from the MAC, leads to different calculations of success rates than the traditional prepayment claim review process, but that is only an educated guess.

We will keep you posted if and when Noridian or any other DME MACs post TPE results data moving forward.

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