“TPE” Audits: Three Strikes and You could be Out (Of Business)!-
Medicare Administrative Contractors (“MACs”) are sending out letters to ambulance service suppliers across the country. These letters indicate that you have been selected for a “Targeted Probe and Educate” review, or “TPE” for short. This is not a prestigious award, and you have not won a prize; you are being audited. Here’s what you need to know if and when you get one of these letters:
The TPE is a new form of pre-payment review, which began as a pilot project before being expanded into all states at the end of 2017. The MAC will begin this process by asking you for documentation from 20 to 40 transports. Based on a review of these claims, you will be assigned an error rate. If your error rate is sufficiently low, then the process ends and you will not be re-selected for review for at least a year. However, if your error rate is “high” (there is no set or published threshold for what is considered a “high” rate of error, so I cannot tell you what expect on that point) the auditor will send you “educational” materials and you will move on to round #2. From some of the MACs, the educational materials you receive are often no more than a data dump of every known regulation and guideline that may apply to ambulance services. This can leave you digging through the educational materials in order to find something relevant to your specific error, however the MAC is supposed to allow for an educational conference call with you as well, so do not miss the opportunity to discuss your claims and errors with them.
In the second round of review, they will give you about two months to let the “education” take effect and give you time to get your errors corrected, then you will be asked for another 20 to 40 claims. The review of these claims will result in your new error rate. If it has decreased to an acceptable level, you are off the hook. If the error rate is still what the MAC considers to be high, you move on to the final round.
If you make it on to round three, you are in harm’s way. A “high” error rate after this third round may result in 100% pre-pay review, referral to a recovery auditor (a ZPIC or RAC) for a post-payment audit, extrapolated damages (note: a sustained high error rate or failure of prior education to correct errors are the two basis upon which a Medicare contractor may use extrapolation to increase the amount you owe them by applying your error rate to all claims you have submitted to them, not just the handful that they actually reviewed), or other action which could include being removed from the Program. Any one of these options will carry huge financial consequences that could be more than a small ambulance service can withstand.
So, what should you do when you get this TPE letter in the mail? First, take it very seriously and make sure it gets into the hands of the proper staff with your service. Second, make sure you gather all of the requested materials and review them to make sure they are complete and legible before you send them back (but be sure to send them back in time!). Third, if the documentation is not complete or parts are illegible (including signatures and/or credentials), there are some things you can appropriately do to correct your errors before they are identified by the MAC, take advantage of that opportunity and make addendums, get signature attestations, gather third party (SNF or Hospital) medical records, etc. And finally, if you have any question about what I mean in the prior sentence, or if you are found with a high error rate after round one, GET HELP! There is too much at stake to go it alone unless you are sure that you can get these errors corrected and drop your error rate quickly. The consequences for failure after the third round of review can be devastating- just remember, three strikes and you could be out!
Christopher Kelly is a lawyer who focuses on regulatory healthcare law as it relates to the EMS and ambulance industry. This article is not intended as legal advice. For more information, he can be reached at EMS Consultants, Ltd., (800) 342-5460 or email to firstname.lastname@example.org.
In addition to meetings with legislators, a Mobile Integrated Health Summit (sponsored by EMSWorld) was held to help provide solutions to the ever changing challenges facing every segment of the out-of-hospital healthcare continuum.
We have been informed that services who have been identified as having over payments greater than $1,000.00 should receive a phone call today (3-24-2015) from AmeriGroup offering to set up payment plans/terms on the refunding the over payments. This approach seems odd due to the fact that we were informed by AmeriGroup that they had no choice but to enforce the TnCare cuts from previous years. We will continue to work on this issue but we also encourage you to consult with your financial and/or legal staff as to your best course of action.
As cool as the experience can be, many EMS professionals are far more comfortable navigating the roads of their local communities than the hallways of Capitol Hill. Please use this guide to learn more about what to expect during EMS On The Hill Day, including:
• Planning your visit
• Tips for getting around Capitol Hill
• Strategies for having effective meetings with members of Congress
• Ideas from your EMS colleagues about making the most of your visit
TASA Board members visited with legislators in Washington D.C. last Monday and Tuesday to discuss changing federal code that will assist in allowing early retirement in Tennessee.
Currently law enforcement and firefighters are the only public safety personnel who are allowed to participate in the 25 years/55 years of age program within TCRS. Federal code change is required before addressing the issue on the State and local level.
Board members visited with Senators Bob Corker and Lamar Alexander along with Congressional representatives; Marsha Blackburn, Chuck Fleischmann, Phil Roe, Scott Desjarlais and Diane Black. Each legislator and their staff expressed their support in changing the necessary federal code. TASA expects this legislation to be introduced during the next session due to fact legislators are currently wrapping up the current session.
Once the code is changed, TASA will immediately work with State legislators to implement the 25/55 early retirement for TCRS. After passage on the State level, local governments will have the option to participate – as this is not a mandate.
It is important to note that the federal code change will not only benefit Tennessee and TCRS, but it will also open the opportunities for other states and non-governmental retirement systems.
Bradley County EMS has been diligently working on this issue for several years and TASA is proud to join them in helping to make this very needed change.
We regret to inform you of the passing of Mike Anderson – Sumner County EMS.
Mr. Mike Anderson, age 46, of Riddleton, died Sunday morning, July 20, at Vanderbilt University Medical Center in Nashville. Mr. Anderson is survived by: wife, Kelly Anderson; daughter, Casey Anderson of Westmoreland,; step-sons, Kyle Oakley and Kain Kotoucek both of Riddleton, Justin Strickland of Raleigh, North Carolina; mother and step-father, Edna and Elbert Stafford of Bradford Hill.
Mr. Anderson is at the Carthage Chapel of Sanderson Funeral Home where his service will be conducted on Wednesday, July 23, at 1:00 PM. Bro. Steve Bode will officiate. Interment in the Smith County Memorial Gardens in Carthage.
Visitation with family and friends will begin Tuesday at 1:00 PM until 8:00 PM and on Wednesday from 10:00 AM until service time at 1:00 PM.
The family has requested memorials to the Sumner County Heart Association.
The July TASA Board meeting date and location has been changed. The meeting will be held on June 30, 2014 immediately following the Mobile Integrated Health/ Community Paramedic meeting which begins at 10am CST at the State EMS office Iris Board Room – 665 Mainstream Drive, Nashville TN.
Please mark your calendar for June 30th for the next meeting on Community Paramedic and Mobile Integrated Healthcare beginning at 10:00a.m. Â We will meet at 665 Mainstream Drive, Nashville, TN in the Iris Board Room starting at 10 am. Â Please RSVP to Donna Tidwell, email@example.com, so we will get a good count on lunches