What is the TPE audit process?

What is a TPE?

A Targeted Probe and Educate (TPE) is an audit program that was rolled out by CMS in 2017. The stated goal of this program is to help providers reduce claim denials and appeals. The TPE works to achieve its goal by educating providers in topics that will help to eliminate common mistakes that lead to recoupment of Medicare payments.

Through the TPE program, CMS (through the MAC) works directly with the hospice agency to identify errors and

• Assist or direct in correcting the errors
• Assist to quickly improve when errors are found
• Provide one-on-one help or education

TPE audits are not random spot checks. They are targeted audits. A hospice is identified based upon MAC data analysis or claim review. A hospice with high error rates or unusual billing practices may also be selected for a TPE. TPEs often focus on items with high national error rates. TPEs also focus on items that pose financial risk to Medicare.

TPEs target hospice agencies that fall within these identified risk categories.  A hospice agency that is compliant with Medicare policies and billing practices will not be selected for a TPE.

What is the TPE audit process?

The TPE audit process begins with a Notification Letter sent from the MAC to the hospice agency.   The Notification Letter explains the TPE program and informs the hospice agency that it has been selected for a TPE audit. It also explains the reason that the agency was included in the TPE and advises that an additional documentation request (ADR) is forthcoming. No response to the Notification Letter is required.

TPE Round 1

The ADR arrives following the Notification Letter. The ADR includes a list of 20-40 claims for which medical records and documentation supporting the claims are requested. This is considered Round 1. The hospice agency must submit the requested documentation.

The MAC reviews the documentation supporting the 20-40 claims to determine if the documentation supports the claims that were submitted.

If the hospice agency is deemed compliant (“no unfavorable findings”) after review of the documents submitted in response to the ADR in round 1, 

• Round 1 ends
• No further reviews on that topic for at least one year

If there are unfavorable findings (issues are noted):

• One-on-one educational sessions are offered to the provider

The hospice should participate in the one-on-one education. This education provides the hospice agency with an opportunity to speak directly with the auditor and discuss the errors identified. During these sessions, the MAC guides the hospice agency through error correction. Following the education there is a 45 day period for the hospice to make improvements (e.g., system improvements, process improvements) before another TPE review by the MAC. If the MAC is satisfied that the errors have been corrected, the audit is closed. However, if more errors are identified the hospice agency will be entered into another audit round.

TPE Round 2

A second ADR is sent requesting another 20-40 claims. The hospice agency submits the documentation which is again reviewed by the auditor. The process followed in TPE Round 1 repeats. If there are unfavorable findings, the TPE advances to Round 3.

TPE Round 3

A third ADR is sent requesting another 20-40 claims. If there are still unfavorable findings in Round 3, the hospice agency is referred to CMS for next steps including:

• Shift to 100% prepay review
• Referral to a RAC
• Extrapolation/recoupment
• Other action, as instructed by CMS

What is the MAC looking for in the TPE audit?

During the TPE audit, the MAC is looking for billing mistakes that cause hospice agencies to be non-compliant with regulations. The most common problem identified during a TPE audit is that the documentation does not support terminal prognosis of six months or less.

What if a hospice agency disagrees with the audit findings?

If a hospice agency disagrees with the audit findings, the agency can appeal the results through the Medical Appeals Process. The hospice agency will need to request a redetermination of overpayment by the MAC.

Where can you find out more?

• CMS explanation of TPE
• Description of TPE process
• Discussion of TPE – SimiTree
• Top TPE errors