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Medicare Claims Mistakes: Are You at Risk for a TPE Audit?

January 10, 2020
Compliance, Documentation, Billing, & Coding By Terry Raser, Senior Consultant

The Centers for Medicare and Medicaid Services (CMS) Target Probe and Educate (TPE) program was initiated in November 2017. The TPE is designed to help providers and suppliers reduce claim denials and appeals. The goal is to quickly improve Medicare Administrative Contractors (MACs) work with facilities to identify errors, correct errors and decrease Medicare billing errors.




The MAC determines the criteria that will be used to target facilities and the focus based on the MAC’s data analytics. Facilities with high claim errors are more likely to be chosen for a TPE audit. For instance, Palmetto GBA—a parent organization of BlueCross BlueShield— has chosen to focus on billing for ultra-high and very high rehabilitation categories. The specific criteria that Palmetto GBA will use has not been identified; however, with the onset of PDPM and CMS stating that rehabilitation minutes should not change, one wonders if there will be some correlation to therapy provision under Resource Utilization Groups (RUGs) compared to PDPM. In client audits performed over the past two months, LW Consulting, Inc.  identified instances where therapy exceeds the 25% cap on group and concurrent therapy. This puts facilities at risk of a penalty that CMS has yet to divulge.

Some common claim errors that have been identified in CMS TPE audits include:

  • Denied for not having an admission order that specifically states “admit to skilled care services”
  • Not recognizing “late entry” orders or documentation as valid
  • Not having some physician orders or therapy evaluations signed prior to billing
  • Therapy being provided 6 days of therapy during the look-back period when the order/plan stated 5 times a week
  • Signature of the certifying physician was not included
  • Eligibility elements are not supported
  • Documentation does not meet medical necessity
  • Missing or incomplete initial certifications or recertifications

How Does the TPE Process Work?

Facilities with high denial rates or unusual billing practices are selected for the TPE. If selected for the TPE, the facility will receive a letter from their MAC. The MAC reviews 20-40 claims and supporting documentation. If the claims are compliant, the facility will be reprieved for a year until the next review. However, if significant changes in the facility billing are detected additional reviews may be conducted. If the claims are not compliant, the facility will receive a letter detailing the results for the audit and will be invited to a one-on-one education session with the MAC. The MAC then helps the facility identify errors on claims and provides education on proper billing. The facility is given a 45-day period to make changes and improve billing after the education is provided. Once the education is provided, the MAC starts the process over and reviews another 20-40 claims. This rounding process can occur up to three rounds before the MAC contacts CMS for next steps if improvement is not noted. These next steps could impose a 100% pre-payment review, extrapolation, Recovery Audit Contractors (RAC) referral or any other consequence CMS chooses.

For more information on TPE audits, read “TPE Audit: What You Need to Know” and “6 Steps to Surviving a TPE Audit.”

The best way to make sure claims are accurate is by faithfully conducting a comprehensive Triple Check Process. If your facility has not had a recent external review of  your Triple Check Process or you are currently in a TPE and need assistance, LW Consulting, Inc. is ready to help. 


For more information, contact Terry Raser at 484-365-2680 or email

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