Large providers are “disproportionately affected” by Targeted Probe and Educate (TPE), CMS’s national medical review strategy, according to an official from a Medicare administrative contractor (MAC).

Because CMS requires MACs, which run TPE, to have sample sizes of 20 to 40 claims per audit, “you are seeing the same large billers bubbling up over and over again because they are the only ones generating enough claims to fall through the loopholes MACs have to get through before they can initiate a probe [audit],” said Cheyenne Santiago, clinical manager of medical review at WPS Government Health Administrators in Omaha, Nebraska.

It’s apparently an unintended consequence of the program’s design “and has been brought to CMS’s attention,” especially with respect to Part A providers, Santiago said at the Sixth Annual Physician Adviser and Utilization Review Team Boot Camp in Los Angeles on July 27. “You don’t want to push all the probes to large billers just because they are large billers.”

Another unintended consequence of TPE, which otherwise has been greeted with cautious optimism by some compliance professionals, is that MACs can’t audit some suspicious claims. One example: claims for noncovered dental services. Medicare generally excludes dental services, but still receives millions of dollars of bills for them annually, scattered among hospitals, Santiago said. “We used to use service-specific edits to catch them, but service-specific edits have been banned from medical-review departments,” she noted. And “the TPE volume is so low, it has created unintentional holes.”