News: CMS rolls out new approach to claim reviews, lightens audit burden

Medicare Administrative Contactors (MAC) have new revised audit targets, according to a CMS announcement  Monday, August 14. MACs will first identify providers with billing errors and then provide corrective educational outreach, in targeted “probe and educate” reviews (TPE), according to Medscape. Under this new process, the MACs select claims for services or items “that pose the greatest financial risk to the Medicare trust fund and/or those that have a higher national error rate,” according to CMS.

Next, the MACs review 20 to 40 claims per service for each of the selected providers—a smaller number than previous probe reviews, according to CMS. If that group of claims shows that the provider is noncompliant, they receive education. This process continues up to three rounds of reviews.

“Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action,” the release says.

Editor’s note: To read Medscape’s entire coverage, click here. To read the entire CMS release, click here. To register for an upcoming ACDIS Live! event about CDI, denials, and audits, click here.