Navigating the CMS “Targeted Probe and Educate” audit initiative

February 7, 2018

With CMS now directing its Medicare Administrative Contractors to focus audits and claim reviews on providers with consistently high error rates, it’s important to understand specifically what shortcomings could put your claims process under the microscope.

CMS has said the goal of this new initiative, dubbed “Targeted Probe and Educate” (TPE), is to prevent fraud, avoid unnecessary payments and to be less of a burden on providers whose billing operations are running smoothly. Select MACs are being asked to choose claims for services that carry a significant financial burden for Medicare, in addition to those that produce consistently high error rates.

Some commons claim errors:

TPE pic

Credit: CMS


The good news is that unlike the old review system, which included all providers for a designated service during the initial round, providers who are already submitting claims with low error rates will be exempted from the review process.

What error rate triggers the TPE cycle?

CMS has not outlined a specific error rate that would automatically trigger the TPE process. Instead, the agency is reserving the right to vary its determination depending on the MAC and specific service under review.

What does the review process entail?

MACs will focus on providers and suppliers who have the highest claim denial rates or who have billing practices that vary significantly from their peers. TPE involves the review of 20-40 claims per provider, per item or service. This is considered a round, and the provider has a total of up to three rounds of review.  After each round, providers/suppliers are offered individualized education based on the results of their reviews.  Providers/suppliers are also offered individualized education during a round to more efficiently fix simple problems.

Credit: CMS

Credit: CMS


What happens if a provider doesn’t improve?

Unfortunately, while this new process will reward compliant providers with less oversight, those who are found to be consistently falling short of CMS’s standard will need to show substantial improvement between reviews to avoid penalties. Those who are determined to still have a poor error rate after three rounds of review could face actions such as referral to a recovery auditor, extrapolation or 100 percent pre-pay review. Providers must display an ability to reduce their claims error rate between rounds of review in order to be removed from the cycle.

What does this mean for the average group?

The bottom line is that it’s more important to ensure your billing staff is informed of this change and is working with you to minimize claim errors, given that even small mistakes could put you under the crosshairs of the new process.

Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

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