Understanding Medicare TPE Audits
                     
Understanding Medicare TPE Audits
Medicare TPE audits: The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & 
Educate (TPE) audit, effective September 1, 2021. Based on data analysis of claims payment, CMS will identify 
areas with the greatest risk of inappropriate program payment.
CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim 
denials and appeals through one-on-one help. Let’s focus on the basics of Medicare TPE audits.
A TPE audit is a close examination of the billing practices that a healthcare provider uses for its Medicare 
claims. The provider’s Medicare Administrative Contractor (MAC) conducts the auditing process.
If unusual billing practices, mistakes, or discrepancies are found between the Medicare claims and the 
healthcare services that were provided to the patient, the MAC will help the provider fix the problems and 
show them how to avoid making them in the future.
Even though the MAC conducts the audit, the Centers for Medicare and Medicaid Services (CMS) is behind 
the auditing program. Providers whose claims are compliant with Medicare policy won’t be chosen for TPE. 
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Understanding Medicare TPE Audits
MACs use data analysis to identify:
• providers and suppliers who have high claim error rates or unusual billing practices, and
• items and services that have high national error rates and are a financial risk to Medicare.
TPE Audit Process
• If chosen for the program, providers will receive a letter from the Medicare Administrative Contractor 
(MAC).
• The MAC will review 20-40 of your claims and supporting medical records.
• If compliant, providers will not be reviewed again for at least 1 year on the selected topics. MACs may 
conduct an additional review if significant changes in provider billing are detected
• If some claims are denied, providers are invited to the one-on-one education session. 
• Providers will be given at least a 45-day period to make changes and improve.
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Understanding Medicare TPE Audits
The majority of providers that have participated in the TPE process increased the accuracy of their claims. 
However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for 
the next steps.
These may include a 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.
Common Reasons for Claim Denials
CMS also mentioned 4 common reasons for claim denials:
• The signature of the certifying physician was not included
• Documentation does not meet medical necessity
• Encounter notes did not support all elements of eligibility
• Missing or incomplete initial certifications or recertification
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Understanding Medicare TPE Audits
Avoiding Medicare TPE Audits
Avoiding a TPE audit failure is essential for healthcare providers, no matter how rarely it happens. The best 
way to make the TPE audit process go smoothly is to have a compliance system in place and follow it to the 
letter.
Regular training sessions with your billing team can ensure that they know and follow the billing guidelines. 
This can keep Medicare billing errors to a minimum and help providers pass TPE audits in as few rounds as 
possible. Another way to avoid Medicare TPE audits is outsourcing your medical billing functions to an 
experienced medical billing company like us. MBC is a leading revenue cycle company providing complete 
medical billing services.
We can assist you in receiving accurate Medicare reimbursement for delivered services. To learn more about 
our billing services, contact us at [email protected] / 888-357-3226
Reference: Targeted Probe and Educate
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