Targeted Probe & Educate Track
Medicare TPE Audit Support
Your MAC flagged your hospice for Targeted Probe and Educate. You'll start getting Additional Documentation Requests, an education session after each round, and a short window to fix your charting — before CMS escalates. The early rounds are the cheap chance to get it right.
3 rounds, then it escalates. If errors aren't corrected after three rounds of review and education, the MAC refers you to CMS — which can mean 100% prepay review, a Recovery Auditor, or extrapolation, where a small sample's error rate is projected across all your claims. That's where a TPE turns into a six-figure problem.
How a TPE audit works
TPE targets hospices whose denial rates or billing patterns deviate from their peers. It runs in up to three rounds:
- The MAC sends a notice, then issues ADRs for 20–40 claims — that's one round.
- You submit documentation; the MAC reviews and sends a results letter with a 1-on-1 education session.
- You get roughly 45 days to fix the problems before the next round.
- If the MAC is satisfied, the audit closes. If not, you move to the next round — up to three.
What CMS is actually looking for
The #1 hospice denial reason in TPE is the same one that sinks Qlarant and PPEO claims: the documentation doesn't support a terminal prognosis of six months or less. Common gaps:
- Certification / recertification of terminal illness with a supporting physician narrative
- Face-to-face encounter documentation for the required benefit periods
- Signed election statement and addendum where applicable
- Service Intensity Add-on (SIA) and visit documentation
- Interdisciplinary Team (IDT) meeting documentation supporting eligibility
How we help
We don't replace your Medical Director's clinical judgment — the medical necessity narrative stays with them. What our clinically-trained reviewers do is spot the eligibility and terminality documentation gaps surveyors flag, before you submit:
- Chart-by-chart review of the claims in your current round — election, addendum, F2F, certification, SIA, IDT
- Coach your team during the education-session window so the next round comes back clean
- Translate the MAC's error findings into specific charting fixes your nurses and physicians can act on
- If claims are denied, we stay with the case through all five Medicare appeal levels until it's resolved — with a strong overturn record
What it costs
Two doors:
$300 / 1-hour Phone Consult
Right call if you just got the TPE notice and need someone to read the round-one ADRs with you and tell you where your real exposure is.
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Chart Review
$300/hr, ~1.5 hrs/claim estimate. 50% deposit, 50% before deliverables. We do the chart-by-chart technical review and hand you a packet ready for your Medical Director's signature. 1-hour wrap-up consultation call included after delivery.
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