CMS ramps up ‘Targeted Probe and Educate’ audits CMS ramps up ‘Targeted Probe and Educate’ audits

CMS ramps up ‘Targeted Probe and Educate’ audits

The Targeted Probe and Educate (TPE) program was launched by CMS nationwide in late 2017 to focus specifically on Medicare providers with high denial rates, the agency says in its fact sheet on the program.

Originally a pilot program localized to a few Medicare Administrative Contractor (MAC) jurisdictions, in 2019 TPE is a nationwide program that can target any provider type. The focus is likely to remain on those Medicare providers that have historically posed the greatest compliance risk, such as home health care agencies – but CMS is in no way limiting the program’s scope.

“Most providers and suppliers will never need TPE,” CMS says reassuringly in its TPE fact sheet. “The process is only used with those who have high denial rates or unusual billing practices. If you are chosen for the program, the goal is to help you quickly improve.

But the second criterion, “unusual billing practices,” has the potential to single out subspecialists such as head-and-neck surgeons or other ENT subspecialties, which are more likely to see complex cases than general ENT physicians.

For now, it’s a good idea to get familiar with how TPE works. If you’re lucky enough to be chosen based on whatever statistical sampling methodology CMS uses to flag providers as having an “unusual” billing pattern, you’ll receive a letter from your MAC notifying you. The MAC will review 20-40 of your claims, requesting additional documentation to fully audit each case, and if some are denied, your providers will get the option of sitting down with a MAC representative for “one-on-one” education.

Whether you accept that education or not, you’ll have a minimum of 45 days to fix the errors identified. You’ll also need to return any identified overpayments, and failure to improve after 45 days (or potentially longer if CMS decides to extend that deadline) will result in a referral to another CMS audit entity such as a Zone Program Integrity Contractor (ZPIC), which is likely to unleash an extrapolation audit and ask for money back based on those findings.


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