Medicare's Target, Probe & Educate (TPE) Initiative

3/13/20251 min read

Have you received a letter from your Medicare MAC wanting records for a specific CPT code? And now that you have sent them, your Medicare Auditor does not agree with your coding? What now?

Target, Probe and Educate (TPE) is one of the many types of audits conducted by the Center for Medicaid and Medicare Services (CMS) requesting documentation. They focus on physicians who they deem most likely to submit noncompliant claims based on data analysis. Currently, these are pre-payment requests for records.

What are some common claim errors?

  • The signature of the certifying physician was not included

  • Encounter notes did not support all elements of eligibility

  • Documentation does not meet medical necessity

  • Missing or incomplete initial certifications or recertification

Who does this TPE apply to?

  • Physicians

  • Hospitals

  • Home Health Agencies

  • Skilled Nursing Facilities

  • DME Suppliers

  • Other Medicare Part A & B providers

How does it work?

  1. If chosen for the program, you will receive a letter from your Medicare Administrative Contractor (MAC).

  1. The MAC will review 20-40 of your claims and supporting medical records.

  1. If compliant, you will not be reviewed again for at least 1 year on the selected topic.

  1. If some claims are denied, you will be invited to a one-on-one education session. Then you will be given at least a 45-day period to make changes and improve before returning to step 2.

What if my accuracy still does not improve?

This should not be a concern for most providers. The majority that has participated in the TPE process increased the accuracy of their claims. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include referral to CMS for additional audits, 100 percent prepay review, exclusion from Medicare participation or potential fraud investigations in severe cases.

Visit www.triumphmps.net or call 214-305-8805 so our experienced consultants can help. content