Targeted Probe and Educate (TPE) is the process that a Medicare Administrative Contractor (MAC) can utilize when providers are selected by Medical Review. The TPE review process may include up to three rounds of a prepayment or post-payment probe review with education.
CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.
TPE’s main goal is to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple – such as a missing physician’s signature – and are easily corrected.
Most providers will never need TPE.
TPE is intended to increase accuracy in very specific areas.
MACs use data analysis to identify:
- Providers and suppliers who have high claim error rates or unusual billing practices, and
- Items and services that have high national error rates and are a financial risk to Medicare.
Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.
CMS is encouraging MACs to use all available sources of data when selecting providers to include in the TPE process. The results of previous P&E programs are one source of data that MACs will use to select providers for review. MACs will also use provider billing and utilization patterns as well as provider-specific error rates. Using the results of previous P&E programs may be of benefit to many HHAs who improved throughout the P&E process, as these providers may not require additional reviews.
Common claim errors
- The signature of the certifying physician was not included
- Documentation does not meet medical necessity
- Encounter notes did not support all elements of eligibility
- Missing or incomplete initial certifications or recertifications
CMS moving to the TPE process for medical review
The results of previous Probe and Educate (P&E) programs have been well received by the provider/supplier community. Additionally, positive results of the TPE pilot program included a decrease in appeals as well as an increase in provider education which resulted in decreased denial rates for a vast majority of providers as they progressed through the P&E process.
These initial P&E programs, however, included all providers/suppliers that billed a particular service. In an effort to refine the P&E programs, CMS determined that efforts would be better directed toward those providers/suppliers who, based on data analysis, provide the most risk to the Medicare program, and not to all providers/suppliers billing a particular item/service.
The 20-40 claim sample size is intended to allow the MACs to review enough claims to be representative of how accurately providers/suppliers have the necessary supporting documentation to meet Medicare rules and requirements, while not being overly burdensome.
If a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review. Additionally, if a provider/supplier submits claims to Medicare for more than one item or service, each item/service could be subject to a separate probe as part of the TPE program. Providers/Suppliers and the specific items and services included in the TPE process are those who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers.
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