What is Targeted Probe and Educate?

When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers that bill a particular item or service rather than all providers/suppliers billing a particular item or service. MACs will focus only on providers/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/supplier, per item or service. This is considered a round, and the provider/supplier 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.

What should a provider/supplier expect during a 1-on-1 education session?

During a one 1-on-1 education session (usually held via teleconference or webinar), the MAC provider outreach and education staff will walk through any errors in the provider/supplier’s 20-40 reviewed claims. Providers/suppliers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed.

Can a provider/supplier be included in multiple TPE probes at the same time?

Yes, if a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review. Additionally, if a provider/supplier submits claims to Medicare for more than one item or service, each item/service could be subject to a separate probe as part of the TPE program. Providers/Suppliers and the specific items and services included in the TPE process are those who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers.