CMS Targeted Probe and Educate Program

We have had CMS on the mind a lot the last few blog posts, and we have one more we want to share. If you are not familiar with it, CMS launched a Targeted Probe and Educate Program over the last few years and have been stepping it up incrementally each year.

What is Targeted Probe and Educate? The program started in one Medicare Administrative Contractor (MAC) jurisdiction in 2016, expanded to 3 more in July 2017 and is currently run in all MAC jurisdictions by the end of 2017.

The goal of the program is to make sure your claims and documentation are compliant with Medicare guidelines. Once a provider is identified, the MAC kicks-off a multiphase process in which 20-40 claims per provider are reviewed. If the provider(s) are found to be non-compliant, they must participate in an one-on-one education session.

MAC then must wait 45 days to do their follow up audit of another 20-40 claims. If the provider is still found to be non-compliant, the provider will be sent for a second round of education. If found non-compliant a third time, the provider will be referred to CMS for possible further action.

Once the provider is found to be compliant, he or she cannot be reviewed again for at least one year on the selected topic. However, if found to be non-compliant in another area, may be reviewed for that area.

Targeted Probe and Educate Workflow

What are some of the common claim errors found?

• Signature of certifying physician was not included

• Documentation does not meet medical necessity

• Encounter notes did not support all the elements of eligibility

• Missing or incomplete initial certifications or re-certifications.

A billing integrity audit is a great way to keep yourself off Medicare’s radar. Legacy does perform billing integrity audits and can assist in identifying if you may be in line for a potential audit. Reach out to us on our Contact Us page and let us know how we can help!


Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

Leave a Comment

Your email address will not be published. Required fields are marked *