The client reached out to see whether we could support the submission of a successful appeal for a Target Probe and Educate (TPE) audit.
Situation
The client underwent a TPE audit that resulted in the denial of 40 cataract surgery claims. After exhausting the first two levels of appeals without success, they sought support from VMG Health to help strengthen their final, third-level appeal. The client’s goal was to reverse the denials and secure payment for the medically necessary cataract surgeries that were previously performed and denied.
Solution
Through fee-for-service support, the ophthalmology experts at VMG Health provided comprehensive guidance throughout the third-level appeal process. The VMG Health Ophthalmology team conducted a thorough review of the denied claims and collaborated closely with the client to craft detailed, customized letters that clearly outlined the medical necessity and supporting documentation for each case. VMG Health provided structured templates, one-on-one meetings, and clear submission guidance to ensure each beneficiary’s submission package was complete, persuasive, and aligned with the Medicare Administrative Contractor’s (Noridian) policy requirements.
Success
As a result of VMG Health’s collaboration with the client, the client received a favorable decision from the third–level appeal. The Qualified Independent Contractor (QIC) overturned the previous denials, and all 40 of the cataract surgery claims were paid. By leveraging VMG Health’s expertise and strategic approach, the client successfully achieved their goal of a positive resolution in the final stage of the TPE appeal process.
