Understanding Medicare TPE Audits

Information has not been updated for a long time

The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) audit, effective September 1, 2021. Based on data analysis of claims payment, CMS will identify areas with the greatest risk of inappropriate program payment. 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. Let’s focus on the basics of Medicare TPE audits. A TPE audit is a close examination of the billing practices that a healthcare provider uses for its Medicare claims. The provider’s Medicare Administrative Contractor (MAC) conducts the auditing process. If unusual billing practices, mistakes, or discrepancies are found between the Medicare claims and the healthcare services that were provided to the patient, the MAC will help the provider fix the problems and show them how to avoid making them in the future. Even though the MAC conducts the audit, the Centers for Medicare and Medicaid Services (CMS) is behind the auditing program. Providers whose claims are compliant with Medicare policy won’t be chosen for TPE. 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.

TPE Audit Process

• If chosen for the program, providers will receive a letter from the Medicare Administrative Contractor (MAC).
• The MAC will review 20-40 of your claims and supporting medical records.
• If compliant, providers will not be reviewed again for at least 1 year on the selected topics. MACs may conduct an additional review if significant changes in provider billing are detected
• If some claims are denied, providers are invited to the one-on-one education session. 
• Providers will be given at least a 45-day period to make changes and improve.

The majority of providers that have participated in the TPE process increased the accuracy of their claims. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for the next steps. These may include a 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.

Common Reasons for Claim Denials

CMS also mentioned 4 common reasons for claim denials:

1. The signature of the certifying physician was not included
2. Documentation does not meet medical necessity
3. Encounter notes did not support all elements of eligibility
4. Missing or incomplete initial certifications or recertification