What is TPE? Targeted Probe and Educate for hospice

TPE, in one sentence

Targeted Probe and Educate (TPE) is a Medicare Administrative Contractor review program in which a MAC selects a specific provider, pulls a probe of 20–40 claims, sends ADRs, evaluates the responses, provides one-on-one education, and then either releases the provider or escalates to another round [1].

TPE is designed to be educational, not punitive — but repeated failure across three rounds can result in the provider being referred to CMS for additional action, including 100% pre-payment review, extrapolation, or referral to the Unified Program Integrity Contractor (UPIC).

How MACs pick TPE targets

MACs use data-driven signals to select providers for TPE, including:

• Above-peer billing patterns (long lengths of stay, unusually high GIP or CHC utilization).
• High denial rates on prior claim reviews.
• Provider-specific edit results triggering thresholds.
• New provider status combined with early utilization patterns.

Selection is not random. Providers on TPE should assume the MAC has a hypothesis about a pattern in their claims and treat the response accordingly.

The 3-round TPE structure

1. Round 1 — MAC pulls a probe of 20–40 claims via ADRs (see What is an ADR?). Provider responds. MAC scores the round for compliance. Provider receives one-on-one education focused on identified issues.
2. Round 2 — Only occurs if Round 1 shows moderate-to-high error rates. Another probe and cycle of ADRs, review, and education.
3. Round 3 — Only if Rounds 1 and 2 did not improve compliance. Final probe and education. If Round 3 still shows problems, the MAC refers the provider to CMS for additional action.

The compliance thresholds are provider-specific and set by the MAC based on the type of service. Passing a round means dropping below the MAC’s threshold, not scoring 100%.

Response strategy for hospice TPE

• Assemble a TPE response squad. Compliance lead + medical director + clinical director + a chart-audit RN. Every claim gets two-pass review.
• Read every claim’s ADR before answering. ADR requests are patient-specific.
• Cover-letter each response with a request-to-page index. MAC reviewers process hundreds of claims per week; make theirs easy.
• Log the MAC’s education takeaways after Round 1 and adjust workflow before Round 2 letters arrive.
• Track denial reasons across the round so the next round’s response addresses the same root causes.

How you get released from TPE

A provider is released from TPE when a round’s error rate drops below the MAC’s threshold. Once released, the provider stays out of TPE for the item/service reviewed for at least a year, unless a new pattern emerges.

Providers who complete TPE cleanly rarely see a repeat. Providers who complete TPE with unaddressed root causes tend to see another round within 12–18 months.