TPE Is Back: Here’s What You Need to Know

The Centers for Medicare & Medicaid Services (CMS) announced that the Targeted Probe & Educate (TPE) program has resumed after being suspended in March 2020 due to the COVID-19 public health emergency. Although some medical reviews resumed in August 2020, the TPE program remained on pause.

What is the TPE program?

TPE is a very focused Medical Review program for home health and hospice. It is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help, with the goal of swift improvement. Medicare Administrative Contractors (MACs) work with agencies in person to identify errors and help correct them.

Common TPE claim errors include:

  • The signature of the certifying provider was not included
  • Face-to-Face (F2F) encounter notes did not support all elements of eligibility
  • Documentation does not meet medical necessity
  • Missing or incomplete initial certifications or recertifications

It differs from post-payment review as it targets providers rather than specific services. TPE is intended to increase accuracy in very specific areas. MACs use data analysis to identify providers 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. If an agency has had high denials from Additional Documentation Requests (ADRs) in the past, they are at a high risk of being selected for the TPE program.

How does it work?

The TPE program consists of up to three rounds of review using 20 to 40 claims selected for ADR (pre or post-payment) for each round. Flagged providers will receive a letter from their MAC notifying them of their selection in the TPE program and the particular reasons behind it, to be followed by the ADR for selected claims. Providers are given 45 days to apply the appropriate changes and improvements. However, it is recommended to respond in 30 days to allow for any delays in technical issues. If an agency is found to be compliant, it will not be reviewed again for at least a year on the selected topic. Otherwise, if claims are denied, they will be required to attend a one-on-one education session to review the greatest areas of need.

How do you respond to TPE?

Promptly prepare a response for all ADRs received even if you think the claim will be denied. Although it is not necessary to insert a cover letter in your response, the MAC may find it useful in identifying key data. Use divider pages to separate documents, and brackets “{ }” or “[ ]”, asterisks “*”, or underlined text in the documentation to draw the reviewer’s attention. Failure to respond will result in the financial risk amount including the total amount for the non-response claims. 

It is recommended that a point of contact is included with the ADR response in the event the MAC contacts the provider by phone for easily curable errors. Make sure to include the requested documentation in the preferred order for home health ADR: (source: CGS Medicare)

  1. FISS Page 7 screenprint
  2. Physician face-to-face documentation
  3. Actual encounter note or progress note
  4. Discharge summary from inpatient stay
  5. Plan of care with physician certification/recertifications
  6. If recertification, include initial certification
  7. Interim/verbal orders
  8. OASIS assessment
  9. Nursing visit notes
  10. Therapy visit notes including evaluations/re-evaluations
  11. Social work visit notes
  12. Aide visit notes
  13. Other relevant documentation
    a) Acute/post-acute care documentation to support home health eligibility

If in round one, your claim denials are not less than the acceptable percentage of your MAC (typically at 15%), you will need to schedule and attend the one-on-one education session and will be given 45 days to improve. 

In the second round, another 20 to 40 claims will be reviewed, which will impact all claims submitted to the Fiscal Intermediary Standard System (FISS) from that date forward, regardless of the date of service. Make sure that your compliance team and billing team are on the same page with these dates. You will have to respond to all ADRs with the goal of showing improvement and that you are below the set financial risk.

If you fail the second round, you move on to round three where the same process will be repeated, and you will be required to attend the training.

How do you avoid TPE altogether?

Unlike surveys and ADRs, TPE is avoidable. Yes, there are best practices to respond to TPEs but it would require additional work and cause operational disruptions that will compromise your established workflows. In reality, the key to maintaining compliance in clinical documentation and avoiding TPE may be in having a robust QA review program supported by a reliable, expert provider. Aside from overseeing documentation compliance, your QA provider should also be ready to support you in responding to ADRs.

As they say in healthcare, prevention is better than cure. You need to make sure you pay attention and comb through charts and claims records carefully to ensure everything is in place to prevent being selected for TPE.


Download Qavalo’s free audit checklist tool to help you review if your charts are survey-ready and at par with compliance standards.