Targeted Probe and Educate (TPE)

TPE is the middle path between a warning and a heavy sanction. MACs use data analysis to find providers and suppliers with high claim error rates or unusual billing practices, and items and services with high national error rates that put Medicare money at risk¹. The manual adds referrals from other contractors and oversight bodies as a trigger, and says reviews can run before or after payment, focused on one item or service at a time².

The rhythm is set by rounds. A round typically samples 20 to 40 claims, and the MAC sizes it so a round takes no longer than about six months. After each round the MAC offers a one-on-one session, by phone, in person or by webinar, about the specific errors found, then allows at least 45 days for changes before selecting new claims. During a round the MAC also contacts the provider about easily cured errors, such as a missing signature that an attestation can fix, so the record can be completed². A provider can leave TPE after any round by showing a low error rate or enough improvement².

The stakes climb after round three. A provider whose error rate is still high is referred to CMS, and the next steps can include more TPE rounds, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor or referral for revocation^1,2. Both the notification letter and the results letters remind providers that 42 CFR 424.535 lets CMS revoke billing privileges for a pattern or practice of claims that fail Medicare requirements². Treat the first ADR of a TPE round as the start of a compliance fix, not just a request for records.