Blog

Targeted Probe and Educate Resumes

CMS has announced it is restarting the Targeted Probe and Educate (TPE) program.  It has been in suspension since the COVID-19 public health emergency.  The program is designed to assist agencies to reduce their claim denials as common claim errors are corrected.  The Medicare Administrative Contractors (MACs) use data to identify providers and suppliers who…

CMS has announced it is restarting the Targeted Probe and Educate (TPE) program.  It has been in suspension since the COVID-19 public health emergency.  The program is designed to assist agencies to reduce their claim denials as common claim errors are corrected.  The Medicare Administrative Contractors (MACs) use data to identify providers and suppliers who have high claim error rates or unusual billing practices, and items and services with high national error rates.  If chosen for TPE, the provider will receive a letter from their MAC.  Then, the MAC will review 20-40 of the provider’s claims and supporting medical records.  If the claims and medical records are compliant, the provider will not be reviewed again for at least 1 year on the selected topic.  If some claims are denied, the MAC will provide one-on-one education and allow at least 45 days to make changes and improve before reviewing more claims and documentation.  Providers have 3 rounds of educational sessions to correct problems.  Failure to improve at that point can result in 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action.  If selected, the goal is to pass the compliance review on the first round.  Providers should review the requested records very carefully to ensure all regulatory elements are present in the submitted documentation.  Common errors are certifying physician signatures, medical necessity, eligibility, and certification/recertification statements.  CMS has previously stated that home health providers who are in the Review Choice Demonstration (RCD) would not be subject to the TPE program.  Contact your MAC if you are on RCD and receive a TPE letter.