Probe and Educate Audit

Targeted Probe and Educate

The Targeted Probe and Educate (TPE) process is based on a data analysis of claims payment, Medicare will identify areas with the greatest risk of inappropriate program payment.

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Key Points

  • Your jurisdiction fiscal intermediary selects providers for the Probe and Educate Audit process (TPE) based on the following:
    • Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or
    • On targeted review and is transitioned to the TPE process based on error rate results; or
    • On service specific review error rate results.
  • Your jurisdiction fiscal intermediary will mail a letter to those who have been selected for TPE review. The letter will outline the reason for selection, and will provide an overview of the TPE process and contact information.

Three rounds of review with up to 20-40 claims selected

  • TPE consists of up to three rounds of review with up to 20-40 claims selected (pre or post payment) with each round. Subsequent rounds will begin 45-56 days after individual provider education is completed. Discontinuation of review may occur if appropriate improvement, and error rate below the target threshold is achieved during the review process.
  • An Additional Documentation Request (ADR) will be generated for each claim selected. your jurisdiction fiscal intermediary has 30 days from the date the documentation is received to review the documentation, and make a payment decision. A letter with the review results will be mailed at the conclusion of each round. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
  • Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. your jurisdiction fiscal intermediary offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available.
  • When high denial rates continue after 3 rounds of TPE, your jurisdiction fiscal intermediary will send a referral to CMS for additional action.
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Our goal is to educate you on how to prepare for the three rounds associated with Probe & Educate audits.

Please contact us for a no obligation consultation regarding how we can help you with Probe & Educate Audits and the appeals process.