The Pitfalls of the CMS’ TPE and SMRC Audits

Over 93% of all doctors accept Medicare, meaning that most physicians have some contact with the Centers for Medicare and Medicaid Services (“CMS”).  Like private health insurers, CMS has multiple tools at its disposal to audit providers and identify alleged overpayments to providers.  Two of the lesser known audits that are exclusive to the CMS are the Supplemental Medical Review Contractor (“SMRC”) and the Targeted Probe and Educate (“TPE”) audits.

A TPE audit should not cause immediate concern.  CMS describes these audits “as a way to help providers reduce claim denials and appeals through one on one help.”  Generally, these audits focus on simple common errors that are easily correctable.  CMS will work with providers through the TPE to educate and correct the identified errors.  TPE audits take place over various phases, with the first two (2) phases providing education and an opportunity to appeal claims that were denied in error. However, if a provider’s error rate is significant throughout the initial phases, continued high error rates can lead to the loss of CMS billing privileges.  

SMRC audits, by contrast, are more akin to a regular commercial audit.  CMS will conduct a statistical analysis to find physicians who bill specific codes at rates that are outliers to the national average.  After these providers are identified, CMS will request a sample of medical records to determine whether there are any coding mistakes. If so, CMS will subsequently issue either an overpayment demand or make manual reductions from the provider’s regular Medicare reimbursements.  There are no “phases” like with TPE audits but there is an education period as well as an opportunity to provide additional records to the auditors in an effort to overturn any denied claim.

How Frier Levitt Can Help

Although an audit or document request from the CMS can be a distressing experience for a medical provider, Frier Levitt is here to help.  We have multiple attorneys experienced with audits from inception to final disposition or settlement.  Our team of attorneys are also experienced in assisting providers with conducting self-audits and ensuring compliance with ever-changing regulatory compliance issues.  Should you receive a TPE or SMRC audit letter or wish to perform a self-audit in preparation for a potential audit, Contact Frier Levitt today.