Skip to main content

The Centers for Medicare and Medicaid Services (CMS) relies on Medicare administrative contractors (MACs) to review medical records for selected claims and educate providers about Medicare fee-for-service billing requirements. MACs are private health care insurers that process Medicare Part A and Part B claims within designated geographic jurisdictions.

In June 2016, CMS began a pilot program called Targeted Probe and Educate (TPE) that directed 1 MAC jurisdiction to "focus only on providers/suppliers who have the highest claim denial rates or who have billing practices that differ significantly from their peers."1 TPE was expanded to include 3 additional MAC jurisdictions in July 2017. On October 1, 2017, it was expanded to include all MAC jurisdictions.

Under TPE, MACs perform up to 3 rounds of a prepayment or postpayment medical review on a targeted provider's claims. The objectives are to determine if a provider is billing and coding per Medicare guidelines, to ensure that the provided services are reasonable and medically necessary, and to enable the provider to fix any identified problems. Each round uses a 20- to 40-claim sample size in order to provide enough claims to represent provider accuracy without being overly burdensome.

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.

  1. Centers for Medicare and Medicaid Services, Targeted Probe and Educate [TPE] Q&As. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-QAs.pdf. Accessed March 30, 2018.
  2. Centers for Medicare and Medicaid Services. Medicare Program Integrity Manual, Chapter 7—MR Reports. https:// www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c07.pdf. Accessed March 30, 2018.

You Might Also Like...

News

CMS Streamlines Approval Processes for Outpatient Clinics

Sep 12, 2024

Updates to the agency's State Operations Manual make it easier to apply for certifications of primary and extension sites.

Article

Is Your Practice ADA Compliant? Part 3 of a 3-Part Series

Jul 24, 2023

Communicating with an individual with a communications disability

Article

Is Your Practice ADA Compliant? Part 2 of a 3-Part Series

Jul 21, 2023

Common Misconceptions on ADA-Compliant Communication