The Medicare Part B Targeted Probe and Educate program, or TPE, is a specific review process instituted by the Centers for Medicare and Medicaid Services (CMS) to improve the accuracy of claims submitted by healthcare providers. Medicare Part B covers outpatient services, including physician services, laboratory tests, and durable medical equipment, making it a high-volume area for claim submissions. The TPE program is designed to identify and correct billing and documentation errors for specific services or providers through a structured, multi-step review cycle. This process focuses on collaboration and education to help providers achieve compliance with federal regulations.
The Purpose and Selection Criteria for TPE Audits
TPE audits are conducted to reduce improper payments and decrease the overall claim error rate within the Medicare system. The program is educational, offering providers a direct pathway to correct deficiencies before more severe action is taken. This approach aims to reduce the volume of claim denials and subsequent appeals, which create administrative burdens for both providers and the government.
The “Targeted” aspect of the program is driven by sophisticated data analysis performed by Medicare Administrative Contractors (MACs). They select providers for TPE based on several risk factors, including having a high error rate for specific services, billing practices that significantly deviate from their peers, or high utilization volumes. A provider may also be selected if they bill for services or items that CMS has identified as having a high national error rate. This data-driven selection ensures audit resources are focused on areas of greatest financial risk to the Medicare program. The MAC is responsible for initiating the audit and managing the entire cycle, acting as the primary point of contact for the provider.
The Three-Step TPE Audit Cycle
The Targeted Probe and Educate process follows a three-step cycle. The process begins when the provider receives a Notice of Review from the MAC, which also includes an Additional Documentation Request (ADR) for a sample of claims.
Probe
The initial phase is the Probe, where the MAC requests medical records for a small sample of claims. The MAC reviews the documentation to determine if it supports the billed services, checking for elements like medical necessity, proper coding, and complete certification. Common errors cited include a lack of sufficient documentation to justify the service or the absence of necessary physician signatures and certifications.
Education
Following the initial probe, if the MAC determines the provider’s error rate exceeds a certain threshold, the process moves into the Education phase. The MAC schedules a mandatory, one-on-one session with the provider to discuss the specific deficiencies found in the claim sample. This personalized education focuses on explaining why the claims were denied and providing guidance on how to correct the documentation or coding issues.
Repeat
After the education session, the provider is given a period to implement the necessary changes to their internal processes. The MAC then initiates the Repeat phase, which involves a second probe review of recently submitted claims for the same topic. The entire probe-and-educate cycle is repeated for up to three rounds, with the MAC assessing the provider’s rate of improvement after each cycle.
Potential Outcomes and Escalation
The TPE process has two potential outcomes: successful completion or escalation. Successful completion is the most favorable outcome and occurs if the provider’s error rate falls below the MAC’s established threshold during any of the three probe rounds.
Upon successful completion, the MAC releases the provider from the TPE process for that specific service or topic. The provider will not be subject to review on that same issue for at least one year. This outcome confirms the provider has implemented effective corrective actions and is compliant with Medicare’s billing and documentation requirements.
The alternative outcome is escalation, which occurs if the provider fails to improve after the third round of the probe-and-educate cycle. If the error rate remains high, the MAC is required to refer the provider to CMS for further action. This escalation can trigger severe consequences:
- 100% prepayment review, where all claims for the service in question are reviewed before payment is released.
- Extrapolation of overpayment, estimating the total overpayment based on the error rate found in the sample.
- Referral to other enforcement entities, such as the Unified Program Integrity Contractors (UPICs), for investigation into potential fraud or abuse.