What to Expect During a TPE (Targeted Probe & Educate) Audit in 2026

As Centers for Medicare & Medicaid Services (CMS) continues to intensify oversight of home health agencies, the Targeted Probe & Educate (TPE) audit process remains one of the most critical compliance touchpoints for agencies in 2026. With CMS’ ongoing focus on reducing improper payments, verifying medical necessity, and ensuring compliance with the Home Health Medicare Conditions of Participation (CoPs), TPE audits have evolved into a structured, data-driven review designed to identify patterns of billing errors and educate agencies before harsher administrative actions are taken.

This article breaks down what home health agencies should expect during a TPE audit in 2026, how to prepare, what documentation CMS contractors are most likely to request, the potential outcomes, and strategies to ensure your agency remains compliant and audit-ready year-round.

1. Understanding the Purpose of a TPE Audit

CMS uses the TPE program to reduce claim denials and prevent fraud by providing education-driven intervention before taking punitive measures. Unlike RAC audits or UPIC investigations, TPE is not designed to be adversarial. Instead, it is a collaborative audit structure where agencies receive targeted reviews of specific claims and subsequent education to correct identified errors.

Key Purpose of the TPE Audit

• Evaluate medical necessity and compliance with billing regulations

• Review adherence to Medicare CoPs for home health

• Identify patterns of claim submission errors

• Provide 1:1 education to agencies on how to correct mistakes

• Reduce future improper billing through improved documentation

TPE audits focus heavily on clinical, technical, and regulatory compliance, making it essential for agencies to have meticulous documentation and an internal compliance culture.

2. What Triggers a TPE Audit in 2026

While CMS randomly selects a small number of agencies, most TPE selections arise from data-driven red flags, including:

Common 2026 TPE Audit Triggers

• High denial rates compared to statewide and national averages

• Frequent use of high-risk HCPCS codes

• Utilization trends inconsistent with similar agencies

• High LUPA avoidance patterns or excessive visits

• Repeated billing errors, such as incorrect OASIS submission or face-to-face documentation issues

• Claims with notable medical necessity concerns, such as long therapy episodes without documented progress

CMS contractors continuously monitor provider data. If your patterns statistically differ from peers, you are placed on a TPE review list.

3. The 2026 TPE Process: Step-by-Step

TPE follows a structured audit protocol that includes three rounds of review, followed by education after each round.

Step 1: Notification Letter

Agencies receive a formal notification from their Medicare Administrative Contractor (MAC) informing them that they have been selected for a TPE review.
This letter includes:

• Subject of the review (e.g., skilled nursing visits, therapy utilization, long lengths of stay)

• Number of claims requested

• Deadline for submission

• Instructions for uploading documentation

Agencies typically have 45 days to respond.

Step 2: Documentation Request (ADR)

MACs request supporting documentation including but not limited to:

Common Documents Requested in Home Health TPE

• Referral and physician orders

• Face-to-face encounter documentation (F2F compliance)

• Start of Care (SOC) OASIS and comprehensive assessment (§484.55)

• Plan of Care (POC) under §484.60

• Visit notes demonstrating skilled need and intervention effectiveness

• Therapy evaluations and 30-day reassessments

• Medication profile and reconciliations

• Homebound status justification under §409.42

• Coordination of care documentation

• Certification and recertification statements

• Discharge planning documentation

Each element must be complete, legible, compliant, and consistent across the record.

Step 3: Medical Review

The MAC reviewer evaluates the claims for:

Primary Areas of Review

• Medical necessity of services provided

• Consistency of documentation across clinicians

• Alignment with CoPs, especially comprehensive assessment and POC requirements

• Proper use of codes and accurate billing

• Evidence that services require skilled care

• Validation of homebound status

• Clear measurable progress toward goals

If documentation is inconsistent, unclear, or missing, the claim is likely to be denied.

Step 4: Education Session

After each round, agencies undergo mandatory 1:1 education, which is intended to correct the root causes of errors identified.

Education may include:

• Review of individual documentation issues

• Recommendations for documentation improvement

• Clarification of Medicare CoPs

• Coding and OASIS accuracy training

• Guidance for preventing recurrences

Agencies must implement corrective actions immediately to reduce errors in subsequent rounds.

Step 5: Possible Second or Third Round Review

If errors persist, the agency proceeds to Round 2 and, if still noncompliant, Round 3.

Failure to show improvement after Round 3 leads to escalation.

4. What’s New in 2026 TPE Audits?

CMS continues to refine TPE to target emerging industry trends. In 2026, agencies can expect:

2026 TPE Enhancements

• More emphasis on OASIS accuracy, especially with the OASIS-E updates

• Increased scrutiny of PDGM visits, focusing on visit variability and LUPA threshold manipulation

• Expanded reviews of telehealth usage in home health

• Higher expectations for objective, measurable skilled documentation

• Stronger emphasis on coordination of care and IDT communication

• Review of compliance with Emergency Preparedness and Infection Control documentation when relevant

CMS is also refining data mining algorithms, meaning agencies with unusual patterns are more quickly flagged.

5. Common Reasons Home Health Agencies Fail TPE Audits

The majority of TPE denials result from predictable documentation issues. Understanding these pitfalls helps agencies avoid them.

Most Frequent TPE Denial Reasons

1. Incomplete or noncompliant face-to-face (F2F) documentation

Missing signatures, non-qualifying encounters, and vague diagnoses are common pitfalls.

2. Inadequate justification of homebound status

Documentation must go beyond generic statements like “patient is weak.”

3. Poor demonstration of skilled need

Notes must show:

• Complexity

• Clinical judgment

• Interventions requiring skilled nursing or therapy

4. Copy-paste or repetitive documentation

MACs frequently flag templated documentation lacking individualization.

5. Missing or inconsistent OASIS assessments

The comprehensive assessment must meet regulatory timelines and accuracy standards.

6. Plan of Care inconsistencies

If interventions are not aligned with POC goals, denials follow.

7. Missing re-assessments

Especially problematic for therapy services.

8. Lack of measurable progress toward goals

CMS expects clear evidence of patient response to skilled interventions.

6. Preparing for a TPE Audit: What Agencies Should Do Now

Proactive readiness is the strongest defense. Here are essential strategies for 2026:

1. Conduct Internal ADR Mock Reviews

Internal audits simulate real MAC reviews and identify documentation gaps early.

2. Strengthen Admission Documentation

SOC documentation must provide:

• A clear picture of patient condition

• Justification of homebound status

• Reason for skilled services

3. Improve Skilled Nursing & Therapy Documentation

Teach clinicians to write notes that:

• Describe complexity

• Demonstrate skill

• Are objective and measurable

• Show progress or lack thereof

4. Reinforce Face-to-Face Compliance

F2F issues are one of the most common denial causes—ensure 100% accuracy.

5. Verify OASIS Accuracy

Inaccurate OASIS submissions affect PDGM reimbursement and audit outcomes.

6. Establish a Compliance Committee

Regular chart reviews ensure continuous compliance with CoPs.

7. Ensure Strong Coding & QA Processes

A robust quality assurance workflow helps catch errors before claims are billed.

7. What Happens if an Agency Fails TPE?

If an agency does not improve after all three rounds, CMS may escalate the case to:

Possible Consequences

• 100% prepayment review

• Extrapolated overpayments

• Referral to UPIC or Zone Program Integrity Contractors

• Suspension of payments

• Potential termination from Medicare program

TPE failure is not a minor issue; the consequences are severe and financially devastating.

8. Best Practices to Ensure TPE Success in 2026

Home health agencies can remain audit-ready by implementing ongoing strategies such as:

1. Maintain an audit-ready documentation standard

Assume every chart will be reviewed.

2. Build a strong clinical education program

Train staff regularly on:

• Skilled documentation

• Homebound criteria

• Medicare CoPs

• Therapy reassessment requirements

3. Use technology and QA tracking tools

Automated alerts help ensure compliance on F2F, OASIS timelines, recerts, and care plan updates.

4. Engage external consultants

Experienced compliance consultants provide:

• Mock audits

• Chart reviews

• Corrective action plans

• Targeted staff training

This reduces risk and strengthens compliance culture.

Conclusion

A TPE audit in 2026 is far more than just a claim review—it is a comprehensive evaluation of your agency’s clinical documentation, regulatory knowledge, internal processes, and alignment with Medicare CoPs. Home health agencies must approach TPE proactively rather than reactively by building a robust compliance infrastructure, ensuring complete and accurate documentation, and continuously educating staff.

TPE is designed to educate, correct, and improve, but agencies that fail to adapt face serious administrative and financial consequences. With strong preparation, ongoing compliance monitoring, and expert support, agencies can navigate TPE successfully and continue delivering high-quality, compliant patient care.

Need Help Preparing for a TPE Audit?

HealthBridge offers comprehensive home health consulting and management solutions, including:

• Mock TPE audits

• Documentation and compliance training

• PDGM and coding review

• Chart audits and QA/QI programs

• Medicare readiness consulting
  

Our experts help agencies stay compliant, avoid denials, and remain survey- and audit-ready throughout the year.

References:

Targeted Probe and Educate (TPE) — CMS Overview
https://www.cms.gov/medicare/medical-review/targeted-probe-and-educate-tpe

Home Health Agencies (HHA) CoPs Final Rule
https://www.cms.gov/medicare/regulations-guidance/legislation/cfcsandcops/hhac

CMS Manual Chapter 7 – Home Health Services
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c07.pdf

Home Health Face-to-Face Documentation Requirements
https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/home-health-face-to-face-encounter