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Targeted Probe and Educate
Last updated Sep 25 2017

CMS has authorized WPS Government Health Administrators (GHA) to conduct the Targeted Probe and Educate (TPE) review process. This is a required process for providers identified by Medical Review. The TPE review process incudes three rounds of prepayment or post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. CMS will determine any additional action, which may include but is not limited to extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor (RAC).

Providers/Suppliers can expect:

  • WPS GHA will notify providers/suppliers in writing of their selection for the topic or CPT code under review, the data reasons for selection and the review process.
  • Provider/supplier reviews will consist of up to three rounds of prepayment or post-payment TPE claim review. WPS GHA will select the topics for review and the providers to be reviewed based on our current data analysis procedures outlines in CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2 PDF Icon
  • WPS GHA may refer providers/suppliers to RAC or UPIC if providers do not respond to ADR requests and submit the requested documentation to WPS GHA.
  • If needed, education will be offered to the provider/supplier throughout the TPE process. Additionally, at the end of each round of claim review WPS GHA will notify the provider/supplier in writing of the results and offer education on identified errors. Providers/suppliers with high error rates will receive on offer for one-on-one education on the specific errors that were identified. The goal for providers/suppliers is to learn from the education and improve the results in the next “round” to a low error category. 
  • Providers/suppliers will move to the next round of claim review if the error rate remains at a high level. Providers/suppliers with a continued high denial rate after three rounds of Targeted Probe and Educate reviews will be referred to CMS for possible for further action.
  • Once a provider/supplier has reached an acceptable error rate the provider will be removed from further review. WPS GHA will continue to routinely monitor data on that service/provider.
  • Note: Discontinuation of the review(s) may occur at any time if appropriate improvement is achieved during the review process.