Targeted Probe and Educate: What Is It?

April 15, 2019
Rick Gawenda

As many of you have found out the hard way, the Centers for Medicare and Medicaid Services (CMS) implemented a new program called Targeted Probe and Educate (TPE) where the goal of the program is to help providers and suppliers reduce claim denials and appeals through one-on-one education.

CMS uses 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.

Upon data analysis, if you are not an outlier in any of the above areas, you won’t be chosen for the TPE. Only CMS and your Medicare Administrative Contractor (MAC) has and knows this data analysis and they are not sharing it with you.

CMS states the 4 most common denials reasons are:

  1. Missing or incomplete certification and/or recertification(s)
  2. The signature of the certifying physician was not included
  3. Documentation does not meet medical necessity
  4. Encounter notes did not support all elements of eligibility

So how does the TPE program? If the provider is selected for TPE, their

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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  1. Rick, do you know of any regulatory statements talking about how long a patient can be put on HOLD for treatment due to things like a family emergency, medical issue, etc?