tci Medicare Compliance & Reimbursement - 2023 Issue Q3

Reader Questions: Know the Facts on Error Percentages and TPE Review

Question: Is there a specific denial percentage for a service that Medicare looks for when determining whether a provider will be part of a Targeted Probe and Educate (TPE) review? Iowa Subscriber Answer: No, not exactly. Though you might think that outlier behavior alone would alert your Medicare Administrative Contractor (MAC) to claims issues, it’s more complicated than that, according to the Centers for Medicare & Medicaid Services (CMS). In fact, it’s a combination of factors from high denial rates, to type of service, and even jurisdiction requirements. “The error percentage that qualifies a provider/supplier as...

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