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.