Targeted Probe and Educate (TPE): How to Pass All Three Rounds and Avoid a UPIC Referral

Few Medicare letters get a provider's attention like a notice of Targeted Probe and Educate review. TPE is a Medicare Administrative Contractor (MAC) medical review strategy in which the MAC reviews a sample of a provider's claims, provides one-on-one education, and repeats the process for up to three rounds if errors continue. TPE is designed to help providers fix problems through education, but providers that do not improve may face serious consequences, including 100 percent prepayment review, extrapolation of overpayments, referral to a Recovery Audit Contractor, or other action. CMS manual instructions also allow MACs to refer suspected fraudulent providers to a Unified Program Integrity Contractor (UPIC) at any time during the TPE process.

The good news is that, according to CMS, most providers that participate in TPE improve the accuracy of their claims. With the right approach, providers can use TPE as an opportunity to strengthen documentation and billing practices and exit the program successfully.

This article explains how TPE works, why providers are selected, what happens in each round, how to prepare strong responses, how to make the most of education sessions, what happens after three rounds, and how to avoid escalation. It is educational and does not replace advice from qualified professionals.

What Is Targeted Probe and Educate?

CMS describes TPE as intended to increase accuracy in very specific areas. MACs use data analysis to identify providers and suppliers with high claim error rates or unusual billing practices, and items and services with high national error rates that are a financial risk to Medicare. CMS states that most providers will never need TPE and that providers whose claims are compliant with Medicare policy will not be chosen.

The Medicare Program Integrity Manual, Chapter 3, Section 3.2.5, provides the rules for TPE. Key features include:

• TPE reviews can be prepayment or postpayment.

• MACs focus on specific providers or suppliers that bill a particular item or service.

• A round typically involves review of 20 to 40 claims per provider or supplier, per service or item, with corresponding education. CMS may approve other sample sizes in rare circumstances.

• The process is typically repeated for up to three rounds, but may involve additional rounds at CMS direction.

• MACs target providers that have historically high claim denial rates, have billing practices that vary from their peers, or when evidence suggests a potential risk to the Medicare Trust Fund.

CMS also operates a Low Biller Probe and Educate Program for providers with lower claim volumes, reviewing fewer than 20 claims per round for up to three rounds, with education after each round.

How TPE Works, Round by Round

Notification

The MAC sends a notification letter explaining the TPE process, the item or service under review, how one-on-one education will be provided, and the possible consequences of continued errors, including referral for further action.

Round 1

• The MAC selects 20 to 40 claims for the targeted item or service and sends Additional Documentation Requests (ADRs).

• Providers generally have 45 calendar days to submit documentation.

• The MAC reviews the documentation and makes payment determinations.

• During the round, the MAC may provide education when it identifies errors that can be easily fixed.

• At the end of the round, the MAC sends a results letter detailing the review findings.

Post-Round Education

• If errors are found, the MAC offers a one-on-one education session.

• CMS describes this education as individualized, claim-specific, and interactive, allowing the provider to ask questions.

• The purpose is to alert the provider to errors and how to resolve them, and to provide education on the review topic to prevent new issues.

The 45-Day Improvement Period

CMS requires MACs to provide a minimum of 45 days after each post-probe education session before selecting new claims for review. CMS's TPE questions and answers explain that MACs can begin sending documentation requests for claims with dates of service no earlier than 45 days after the previous one-on-one education. If a provider declines to schedule education within a reasonable time, subsequent reviews will be for claims with dates of service no earlier than 45 days from the education offer.

This means the improvement period is the provider's opportunity to change practices before new claims are selected.

Rounds 2 and 3

The process repeats with new claims. If the provider becomes compliant at the end of any round, the MAC discontinues the TPE process. CMS manual instructions provide that MACs conduct follow-up review in one year, or sooner if data analysis indicates changes in billing patterns or a potential risk to the Medicare Trust Fund.

Round Duration

CMS manual instructions state that MACs should choose the volume of claims so that a round does not take longer than approximately six months. If a provider's billing volume decreases, the MAC may close the round with the existing claims at the six-month mark.

What Happens If You Do Not Pass?

According to CMS, problems that fail to improve after three rounds of education are referred to CMS for next steps, which may include:

• 100 percent prepayment review.

• Extrapolation of overpayments.

• Referral to a Recovery Audit Contractor.

• Referral for revocation.

• An additional round of TPE at CMS's direction.

• Other action.

CMS manual instructions state that referrals include the reason the provider was selected, TPE review results, results of appealed denials to the extent available, education provided or offered and refused, and other relevant information.

The UPIC Connection

CMS manual instructions provide that MACs shall refer suspected fraudulent providers to the UPIC at any time during the TPE process. A UPIC referral is not a normal outcome of failing TPE due to documentation errors, but patterns that suggest potential fraud, such as services not rendered, falsified documentation, or identity misuse, can lead to UPIC involvement. UPICs can request records with a 30-day response time, conduct interviews and site visits, recommend payment suspensions, and refer matters to law enforcement.

Non-Responses Count as Errors

CMS instructions state that non-responses to ADRs count as errors when calculating a provider's error rate. Failing to respond is one of the fastest ways to fail a TPE round.

How to Pass Round 1

Read the Notification Letter Carefully

Identify the specific item or service under review, the reason for selection if stated, and the MAC contact information. Understanding why you were selected helps focus your preparation.

Study the Coverage Requirements

Review the applicable national coverage determinations, local coverage determinations, policy articles, and CMS manual provisions for the targeted service. Make a checklist of every required documentation element.

Build a Response Team

Include a coordinator to track ADRs and deadlines, a clinical reviewer to assess medical necessity and documentation, and a billing or coding specialist to verify coding accuracy.

Respond to Every ADR on Time

• Log every ADR as soon as it arrives.

• Respond well before the 45-day deadline.

• Use the MAC's preferred submission method and keep proof of submission.

Submit Complete Documentation

• Include all records that support the claim, not just the note for the date of service. CMS instructions allow reviewers to consider documentation related to the beneficiary's condition before and after the service.

• Include orders, certifications, plans of care, progress notes, test results, and signature attestations as appropriate.

• Make sure records are legible, signed, and dated.

• Consider a cover sheet that lists enclosed documents and points to where key requirements are met.

Never Alter Records

Late entries and addenda must follow Medicare documentation rules and be clearly identified and dated. Records must never be created or altered to appear as though they existed earlier.

How to Make the Most of the Education Session

The one-on-one education session is one of the most valuable parts of TPE. To make the most of it:

• Schedule promptly. Delaying education does not delay the next round and wastes improvement time.

• Prepare questions. Review the results letter and list questions about each denial.

• Invite the right people. Include clinicians, documentation staff, coders, and billing staff who can implement changes.

• Take detailed notes. Record the specific guidance provided for each error.

• Ask for resources. Request references to the relevant policies, documentation checklists, and MAC educational materials.

• Confirm understanding. Make sure you understand what compliant documentation looks like for the service.

Questions to Ask During the Education Session

Preparing specific questions helps turn the education session into practical improvements. Useful questions include:

• For each denied claim, what specific documentation element was missing or insufficient?

• What would compliant documentation look like for this service, and are there examples or checklists available?

• Which coverage determinations, policy articles, or manual sections were applied?

• Are there errors that could be addressed through signature attestations or other acceptable methods?

• Were any denials due to records that were not received, and if so, how can we confirm receipt in the future?

• What are the most common errors the MAC sees for this service among other providers?

• How will the next round's claims be selected, and when should we expect new ADRs?

How to Use the 45-Day Improvement Period

The time between education and the next round is the provider's chance to fix problems. Practical steps include:

1. Analyze the root causes of each denial. Determine whether errors stem from missing documents, insufficient clinical detail, signature issues, template problems, workflow gaps, or coding errors.

2. Update processes. Revise documentation templates, intake procedures, ordering workflows, and checklists.

3. Retrain staff. Provide targeted training to the clinicians and staff responsible for the errors.

4. Implement pre-billing review. For the targeted service, review documentation before claims are submitted to catch errors.

5. Conduct a mini-audit. Review a sample of recent claims to confirm that improvements are working before the next round begins.

6. Document your efforts. Keep records of training, process changes, and internal audits. This record can be valuable if the provider is referred to CMS.

How to Pass Rounds 2 and 3

• Apply every lesson from earlier rounds consistently.

• Continue pre-billing review for the targeted service.

• Monitor ADRs closely and respond early.

• Track your error rate by round and identify any remaining issues.

• Continue using MAC educational resources.

Appeal Denials You Believe Are Incorrect

TPE denials are initial determinations that can be appealed through the Medicare claims appeal process, beginning with a redetermination request to the MAC, generally within 120 days. CMS manual instructions state that referrals after TPE include results of appealed denials to the extent available, so successful appeals can matter. Providers should appeal denials they believe are incorrect, while also addressing legitimate documentation problems.

Keeping Records of Your Improvement

Documenting improvement efforts serves two purposes. First, it helps the organization confirm that changes are working. Second, it creates a record that may be relevant if the provider is referred to CMS after three rounds, since referrals include information about education provided or offered and refused. Useful records include education session notes, updated policies and templates, training attendance, pre-billing review results, and internal audit findings.

Common Reasons Providers Fail TPE

• Not responding to ADRs or responding late.

• Sending incomplete records, such as missing orders or certifications.

• Documentation that does not support medical necessity.

• Missing or invalid signatures.

• Coding that does not match documentation.

• Not attending or not acting on education sessions.

• Not changing processes between rounds.

• Relying on templates that produce generic or cloned documentation.

Service-Specific Considerations

TPE topics vary by MAC and over time, but commonly involve services with high improper payment rates. CERT data published by CMS identifies service types with significant improper payments, which often shape medical review priorities. For example:

• Home health providers should focus on homebound status, face-to-face encounter documentation, the plan of care, and certification requirements.

• Hospice providers should focus on terminal prognosis documentation, certifications and recertifications, and the election statement.

• Durable medical equipment suppliers should focus on valid orders, medical necessity documentation, and proof of delivery.

• Inpatient rehabilitation facilities should focus on documentation supporting the need for intensive rehabilitation.

• Physicians and other practitioners should focus on documentation supporting the level of evaluation and management service billed.

A Hypothetical TPE Scenario

Consider a home health agency selected for TPE on home health episodes. In Round 1, the MAC reviews 30 claims and denies 12. The results letter shows that most denials involved insufficient documentation of homebound status and missing elements in the face-to-face encounter documentation.

The agency schedules education promptly and brings its clinical manager, intake coordinator, and billing lead. During the session, the MAC explains what documentation would have supported homebound status and how the face-to-face encounter must relate to the primary reason for home health services.

During the 45-day improvement period, the agency revises its intake checklist, updates its assessment template to prompt for specific functional limitations, trains clinicians, and adds a pre-billing review for every new episode. It also audits ten recent episodes to confirm that the changes are working.

In Round 2, the MAC reviews 25 claims and denies 3. The agency attends education again and fixes the remaining issues, which relate to signatures on certain plans of care. In Round 3, the MAC finds the agency compliant and discontinues TPE. The agency keeps its pre-billing review in place and continues internal audits.

Building a TPE Response Checklist

A written checklist helps keep responses consistent across rounds:

• Log each ADR with claim number, beneficiary, date of service, and deadline.

• Confirm the coverage requirements for the targeted service.

• Gather orders, certifications, plans of care, assessments, visit or progress notes, test results, and proof of delivery as applicable.

• Confirm signatures and dates on all key documents.

• Prepare signature attestations when appropriate.

• Complete a clinical review against the coverage checklist.

• Complete a quality check for completeness and legibility.

• Prepare a cover sheet listing documents and highlighting key requirements.

• Submit before the deadline and save proof of submission.

• Record the outcome and route denials for appeal review and root cause analysis.

Keeping Leadership Informed

TPE affects revenue, workload, and compliance risk, so leadership should be informed throughout the process. Regular updates to executives and the compliance committee should include the targeted service, round status, error rates, key denial reasons, corrective actions, and upcoming deadlines. Leadership involvement helps ensure that staff have the time and resources needed to make lasting improvements.

Avoiding Escalation Beyond TPE

• Treat TPE as a serious compliance matter, involving leadership and the compliance officer.

• Keep detailed records of everything you do to improve.

• Do not ignore patterns that suggest deeper problems, such as services that cannot be documented as provided.

• If internal review identifies overpayments outside the TPE sample, evaluate obligations under the 60-day overpayment rule at 42 CFR 401.305.

• If you receive a UPIC request or other indication of a fraud investigation, contact experienced legal counsel promptly.

Frequently Asked Questions

How many claims are reviewed in a TPE round?

Generally 20 to 40 claims per provider or supplier, per item or service. Low-volume providers may have fewer than 20 claims reviewed under the Low Biller Probe and Educate Program.

How long do I have between rounds?

CMS requires at least 45 days after each post-probe education session before new claims are selected. New reviews involve claims with dates of service at least 45 days after education or the education offer.

What happens if I pass a round?

If you are compliant, the MAC discontinues the TPE process. CMS manual instructions provide for follow-up review in one year, or sooner if data indicates a change in billing patterns or risk.

What happens after three failed rounds?

The MAC refers the provider to CMS, which may direct 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, referral for revocation, additional TPE rounds, or other action.

Can TPE lead to a UPIC investigation?

MACs may refer suspected fraudulent providers to the UPIC at any time during TPE. Documentation errors alone generally lead to education and escalated review, but signs of potential fraud can lead to UPIC involvement.

Can I decline the education session?

Providers can decline education, but CMS's TPE questions and answers explain that if a provider declines to schedule education within a reasonable time, the next round will involve claims with dates of service at least 45 days after the education offer. Declining education removes an important opportunity to learn how to correct errors.

Do denials in TPE count against me if I win on appeal?

CMS manual instructions state that referrals after TPE include results of appealed denials, to the extent available at the time of referral. Successful appeals can therefore be relevant when CMS decides on next steps.

Conclusion

Targeted Probe and Educate gives providers a structured opportunity to correct errors through review and education. Passing TPE requires responding to every ADR on time, submitting complete and accurate documentation, actively participating in education sessions, using the improvement period to fix root causes, and consistently applying lessons in later rounds. Providers that treat TPE seriously can often exit the program successfully and emerge with stronger documentation practices.

Failing to improve, on the other hand, can lead to 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, revocation, or, where fraud is suspected, UPIC involvement. A proactive, well-documented response is the best protection.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that specializes in Medicare medical review, Targeted Probe and Educate response, and documentation improvement. We help providers manage ADRs, review records before submission, prepare for education sessions, analyze root causes of denials, implement process improvements and pre-billing review, and prepare appeals. If your organization has been selected for TPE or wants to reduce the risk of selection, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-and-educate-tpe

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate (TPE) Questions and Answers. https://www.cms.gov/files/document/updated-tpe-qas.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-08, Transmittal 819. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R819PI.pdf

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-20 One-Time Notification, Transmittal 2239. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R2239OTN.pdf

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate Flow Chart. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-Pilot-Flow-chart06-20-17v9-final.pdf

• Centers for Medicare & Medicaid Services. Hospital Patient Status Review Frequently Asked Questions. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/inpatient-hospital-reviews-faqs

• Centers for Medicare & Medicaid Services. Medicare and Medicaid Program Integrity Report to Congress 2023. https://www.cms.gov/files/document/fy2023-medicare-and-medicaid-report-congress.pdf

• Centers for Medicare & Medicaid Services. FY 2020 Medicare and Medicaid Integrity Programs Annual Report to Congress. https://www.cms.gov/files/document/fy2020-medicare-and-medicaid-annual-report-congress.pdf

• Centers for Medicare & Medicaid Services. Comprehensive Error Rate Testing (CERT). https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert

• Centers for Medicare & Medicaid Services. 2024 Medicare Fee-for-Service Supplemental Improper Payment Data. https://www.cms.gov/files/document/2024-medicare-fee-service-supplemental-improper-payment-data.pdf

• Centers for Medicare & Medicaid Services. Original Medicare (Fee-for-Service) Appeals. https://www.cms.gov/medicare/appeals-grievances/fee-for-service

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• U.S. Department of Health and Human Services, Office of Inspector General. General Compliance Program Guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/