Targeted Probe and Educate (TPE) Process

Change Request 10249 (PDF, 241 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. Based on data analysis of claims payment, Palmetto GBA will identify areas with the greatest risk of inappropriate program payment. Refer to the Active Medical Reviews article for a list of review topics. All service-specific reviews will be phased out.  

Palmetto GBA selects providers for the TPE process based on the following:

  • Analysis of billing data indicating aberrancies that may suggest questionable billing practices or
  • On targeted review and is transitioned to the TPE process based on error rate results or
  • On service specific review error rate results

Palmetto GBA will mail a letter to those who have been selected for TPE review. The letter will outline the reason for selection, and will provide an overview of the TPE process and contact information.

  • TPE consists of up to three rounds of review with 20-40 claims sample selected (pre or post payment) for each round
  • Subsequent rounds will begin 45-56 days after individual provider education is completed.  Discontinuation of review may occur if appropriate improvement and compliance is achieved during the review process.
  • An Additional Document Request (ADR) will be generated for each claim selected 
    • For pre-pay reviews, Palmetto GBA has 30 days from the date the documentation is received to review the documentation, and make a payment decision
    • For post-pay reviews, Palmetto GBA has 60 days from the date the documentation is received to review the documentation, and make a payment decision

Note: Non-response denials count as an error when calculating the error rate.  Palmetto GBA recommends using eServices, our secure online web portal to submit documentation in response to medical review ADRs and when/if additional documentation is requested throughout the review process.  You may refer to the eServices User Manual (PDF, 7.83 MB) for instructions. If you are not already registered to use eServices, refer to Registration on page 17.

Prior to the conclusion of each round, the medical reviewer will call all providers with moderate to high error rate to discuss the summary of the errors found. 

At the conclusion of each round, a letter with the review results will be mailed. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part.

When high denial rates continue after three rounds of TPE, Palmetto GBA will send a referral to CMS for additional action.