Home health agencies across the United States face growing scrutiny from the Centers for Medicare & Medicaid Services (CMS). With increasing emphasis on compliance, accurate billing, and proper documentation, many agencies have found themselves subject to medical review programs. One of the most impactful of these programs is Targeted Probe and Educate (TPE).
TPE is not simply a billing audit—it is a structured process designed to help agencies improve compliance while reducing the burden of unnecessary denials. For home health providers, understanding how TPE works, why it exists, and how to prepare for it can mean the difference between maintaining smooth operations or facing claim denials, payment delays, and reputational risk.
This article provides a comprehensive overview of TPE: its purpose, process, best practices for preparation, and strategies to ensure your agency is compliant.
What is Targeted Probe and Educate (TPE)?
Targeted Probe and Educate (TPE) is a medical review process implemented by CMS through the Medicare Administrative Contractors (MACs). Its goal is to ensure providers and suppliers are submitting claims correctly and in compliance with Medicare guidelines. Unlike random audits, TPE is targeted—agencies are selected for review based on data that indicates high error rates, unusual billing patterns, or potential non-compliance.
Instead of penalizing providers immediately, TPE emphasizes education. Agencies under review receive individualized education from their MAC if claims are denied due to documentation or billing errors. This allows providers to correct issues before facing further audits or enforcement actions.
Why Was TPE Created?
CMS created TPE as part of its broader program integrity strategy. Historically, providers faced various forms of medical review, such as Recovery Audit Contractor (RAC) audits or Comprehensive Error Rate Testing (CERT) reviews. However, these programs often emphasized penalties over education.
The TPE program shifts the focus to prevention and correction. The reasoning is simple: many billing errors stem not from fraud but from misunderstanding or misapplying complex Medicare rules. By educating providers, CMS hopes to:
Reduce claim denials.
Prevent unnecessary appeal backlogs.
Promote consistent compliance.
Focus enforcement resources on providers who repeatedly fail to improve.
For home health agencies, this approach offers an opportunity to strengthen compliance without immediately risking severe penalties.
How Does TPE Work?
The TPE process follows a structured format with three rounds of review. Here’s what agencies can expect:
1. Selection for Review
MACs use data analysis to identify agencies with higher-than-average denial rates, billing outliers, or questionable utilization patterns. Selection does not necessarily mean wrongdoing, but it does indicate a need for closer review.
2. Probe Sample
The MAC will request 20–40 claims from the agency. These claims are reviewed for compliance with Medicare coverage and documentation requirements.
3. Results & Education
After the review, the MAC shares results. If claims are denied, the agency receives one-on-one education sessions to address errors and improve documentation.
4. Subsequent Rounds
If errors persist, CMS may conduct up to three rounds of TPE. Each round involves another set of claim samples and additional education.
5. Escalation
Agencies that fail to improve after three rounds may face escalated actions, including:
Agencies that demonstrate improvement are released from review for at least one year.
Common Reasons Home Health Agencies are Targeted
Understanding why an agency may be flagged for TPE is crucial. Common triggers include:
High denial rates compared to peer agencies.
Frequent billing errors, such as incorrect codes or missing physician certifications.
Utilization concerns, including unusually high visit counts or long episodes.
Documentation deficiencies, such as missing signatures, incomplete OASIS assessments, or lack of medical necessity justification.
Patterns in ADRs (Additional Documentation Requests) that suggest repeated compliance gaps.
Documentation: The Key to Success in TPE
The most critical factor in passing TPE is thorough, accurate, and compliant documentation. For home health agencies, documentation must clearly establish:
Eligibility – The patient meets Medicare’s home health criteria: homebound status, skilled need, and under a physician’s plan of care.
Medical Necessity – Skilled services are reasonable and necessary for the patient’s condition.
Plan of Care – The plan is established, reviewed, and signed by the physician, with goals and interventions clearly documented.
Consistency – All documentation (physician orders, visit notes, OASIS, and discharge summaries) aligns and supports the claim.
Errors often occur when agencies fail to demonstrate medical necessity or when inconsistencies appear across documentation sources.
Preparing for TPE: Best Practices for Home Health Agencies
To minimize the risk of errors and ensure success in a TPE review, agencies should adopt proactive compliance strategies.
1. Conduct Internal Chart Audits
Regularly audit a sample of claims to ensure all required documentation is present and consistent. This helps identify problems before CMS does.
2. Train Clinical Staff
Nurses, therapists, and caregivers should understand how their documentation impacts compliance. Education should emphasize clarity, completeness, and accuracy.
3. Standardize Processes
Develop checklists for admissions, recertifications, and discharges to ensure nothing is overlooked.
4. Monitor Denials & ADRs
Track denial reasons and ADR requests from your MAC. Patterns in denials often point to larger systemic issues that need correction.
5. Use Compliance Technology
Leverage EMR systems that include compliance prompts, alerts for missing data, and built-in audit tools.
6. Engage External Experts
Sometimes, outside consultants can provide unbiased reviews and training that internal staff may miss.
What to Expect During a TPE Education Session
Education sessions are not punitive—they are designed to help agencies improve. A MAC representative will:
Review denied claims with the agency.
Explain why the claims did not meet Medicare requirements.
Provide guidance on how to improve documentation and compliance.
Offer resources, such as manuals and training materials.
Agencies should treat these sessions as opportunities to strengthen their compliance programs, ask questions, and clarify uncertainties.
Consequences of Failing TPE
While TPE emphasizes education, failure to improve can have serious consequences. Agencies that do not correct errors after three rounds face:
Prepayment Review – Every claim submitted is reviewed before payment, significantly delaying revenue.
Extrapolated Overpayments – CMS may extrapolate errors to a larger claim population, leading to large recoupments.
Referral to Other Review Programs – Persistent non-compliance can trigger RAC or UPIC audits.
Loss of Medicare Billing Privileges – In severe cases, CMS can revoke billing rights.
For agencies dependent on Medicare reimbursement, failing TPE can threaten financial viability.
Building a Culture of Compliance
Passing TPE isn’t just about preparing for an audit—it’s about building a culture where compliance is integrated into daily operations. Home health agencies should strive to:
Foster open communication between administrative and clinical staff.
Encourage staff to ask questions when uncertain about documentation.
Make compliance a shared responsibility rather than a top-down directive.
Recognize that compliance not only prevents denials but also improves patient care and outcomes.
The Role of ADRs (Additional Documentation Requests)
One of the most common outcomes of TPE reviews is the receipt of ADRs (Additional Documentation Requests). These require agencies to submit supporting documentation to justify claims.
Timely and complete responses to ADRs are critical. Missing or incomplete documentation often leads to claim denials. Agencies must ensure that:
All requested documents are gathered quickly.
Documentation is organized and clearly labeled.
Responses are submitted within the MAC’s deadline.
This is an area where many agencies struggle, and professional support can make a significant difference.
Conclusion
Targeted Probe and Educate (TPE) is more than just another audit—it is an opportunity for home health agencies to strengthen compliance, refine documentation practices, and reduce risk. By approaching TPE with preparation, agencies can not only survive the process but also emerge stronger, with better systems and reduced denial rates.
The key to success lies in proactive chart audits, staff education, standardized processes, and readiness to respond to ADRs. Agencies that invest in compliance today will safeguard their financial stability and maintain trust with CMS tomorrow.
Need Help with ADRs?
TPE often results in Additional Documentation Requests (ADRs), and responding effectively is essential to avoid denials. If your agency is struggling with ADR preparation, chart reviews, or compliance guidance, HealthBridge Consulting can help.
With proven expertise in Medicare compliance for home health and hospice, HealthBridge Consulting provides ADR response support, documentation reviews, and education for staff. By partnering with experts, your agency can minimize denials, maintain compliance, and stay focused on delivering quality patient care.
Contact HealthBridge Consulting today for assistance with ADRs and TPE compliance.
