CMS announced on August 12, 2021 that the MAC’s Targeted Probe and Educate (TPE) Program is restarting after a temporary pause during the Public Health Emergency. TPE involves a process of selecting providers identified based on data analysis as being at high risk for overpayments, or with unusual billing practices compared to peers, and/ or with high rates of denial. The MAC conducts medical review of 20-40 claims to determine compliance with supportive documentation and billing requirements. Medical review is followed by a minimum of a 45 day improvement period during which the provider may participate in education with the MAC. Providers may be required to participate in up to 3 rounds of TPE if accuracy rates fail to improve after which they may be referred to CMS for next steps. The CMS TPE fact sheet  lists the following common claim errors including, but not limited to (1) documentation fails to support medical necessity, (2)errors with certification/recertification documentation, (3)physician signature issues, and (4) problems with encounter notes not supporting all required elements.  Access the August MLN article announcing TPE resumption and the Q&A document to learn more.

Wonder how your facility will fare under medical review? Contact Proactive for a compliance check-up of your Medicare claims and feel confident facing TPE.


Amie Martin OTR/L, CHC, RAC-CT, MJ, Proactive Medical Review

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