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Effective Oct. 1, 2017, the Centers for Medicare & Medicaid Services (CMS) implemented the Targeted Probe and Educate (TPE) program for medical record reviews across all Medicare administrative contractors (MACs) in order to identify common errors in claims and help providers improve claim accuracy in those very specific areas. Note: CMS-directed prior-authorization and automated reviews fall outside of the TPE program.
Using data analysis, MACs identify providers with high claim error rates or unusual billing practices, as well as items and services that pose a financial risk to Medicare due to their high national error rates. Providers that don’t have high claim error rates or unusual billing practices won’t participate in TPE. For those that do, here are the basics of how it works, according to CMS’ TPE handout and Transmittal 2035:
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