TPE, ADRs, and Contractor Audits

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MJS Compliance offers a robust program to providers who are receiving record requests as part of CMS’s Targeted Probe and Educate program, Additional Development Requests (ADRs), Medical Review Probes, RAC Reviews, Contractor Audits, OIG investigations and any other request received by the Provider.

We work independently or with your attorneys to provide you with quick service that is both efficient and cost-effective. Our work is performed based upon a pre-engagement quote that ensures you will not have hidden fees attached at the end of the work. Our fees are reasonable and lower than industry standards. Yet our quality, expertise and performance are state-of-the art for healthcare providers.

Here are some examples:

 CMS has designed the TPE program to help providers and suppliers reduce claim denials and appeals. But the underlying secret is that providers are “targeted” based upon utilization, high claim error rates, or unusual billing practices AND items or service that have high national error rates and are a financial risk to Medicare.

Not every provider will be selected, but when you are “targeted” it is both stressful and costly. TPE requirements typically include 20-40 claims for up to three rounds of review. If the provider has no denials, it moves on to another year before possible selection again. BUT, if there are denials, then additional claims may be selected. If improvement is not made in follow-up rounds, CMS can initiate other action including “100 percent prepay review of all claims, extrapolation, referral to a Recovery Auditor or other action.

MJS is actively involved with providers who are part of TPE issues. The MJS compliance team reviews documentation prior to submission, projects denial rates based upon its reviews, recommends corrective action to implement in the corrective phase, and participates in the provider education sessions when the provider requests it.

Requests for records and follow-up audits are increasing for the healthcare providers as contractors work jointly with managed care providers to eliminate fraud, waste, and abuse in healthcare. MJS anticipates an increase in record reviews as part of the planned Department of Government Efficiency (DOGE) initiatives. 

MJS has been, and will continue to be, an advocate for balancing health care delivery with reimbursement requirements for all provider types. Our compliance team will provide both pre and post record reviews to assist the provider community in presenting its best case for coverage at front end rather than after denials have been received. However, we also work with denial reports in preparation for appeals to the auditing entity.