1. Anthony, Maureen PhD, RN

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Has your agency been selected for the Centers for Medicare and Medicaid Services (CMS) Targeted Probe and Educate (TPE) program? For those who are not familiar with TPE, it began as a pilot program in some areas to address healthcare providers with high claim denials or those whose billing practices vary significantly from their peers. In 2017, it expanded to include all healthcare providers who received payments from Medicare Part A or Part B. The CMS website states: "The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple - such as a missing physician's signature - and are easily corrected" (, 2019).

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As with most things from CMS, the intent sounds good. TPE sounds like CMS is going to help agencies better understand what CMS is looking for in terms of documentation to support the criteria for coverage. But the reality is that it ends up feeling like another way to try and find ways to not pay agencies for the care provided.


Here are several interesting points from someone who has experienced TPE:


1. If you disagree with the findings of the review, you can appeal the results. The appeal must occur prior to the education. If you are being denied visits based on lack of skill or homebound status and want to understand why, it makes sense that you would want to receive education on their reasoning and be able to apply that education to the appeal. But you have to complete the appeal before receiving education. Once receiving the education, you can't appeal. Also, the education is just a repeat of the information on the denial determination letters.


2. CMS has decided to add a new focus for another round of TPE-so now we have to worry about another round of TPE for a new reason.


3. The CMS website states that TPE is only for those organizations that have a high rate of claim denial or unusual billing practices-but our denial rate is low and a majority of agencies in my state received notifications for TPE. Does that mean that most of the agencies in my state have "unusual billing practices"?



We know that there is a lot of fraud and abuse in home healthcare. But there have to be better ways to discover and investigate other than reviewing individual records for one-off documentation errors.


REFERENCE (2019). Targeted, probe and educate. Retrieved from[Context Link]