How to Use TPE Plans for Compliance Auditing and Monitoring 

When conducting their periodic risk assessments, most compliance professionals use the OIG’s Work Plan or recent DOJ enforcement actions to help determine how best to deploy time and resources on auditing and monitoring efforts. There’s another incredibly helpful resource that some might not be as familiar with: the list of services that Medicare Administrative Contractors (MACs) include in their Target, Probe and Educate (TPE) plan.  

TPE is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. According to the Centers for Medicare and Medicaid Services (CMS), TPE’s goal is to facilitate quick improvement and enable MACs to work with providers to identify specific errors and correct them. For example, MACs use data analysis to identify: 

• Providers and suppliers who have high claim error rates or unusual billing practices.
•  Items and services that have high national error rates and are a financial risk to Medicare. 

MACs typically list the items and services they have currently identified for their TPE efforts.  By way of example, here are two TPE pages on MAC websites: 

• Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00161300
• Palmetto: https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/T9BELW565I~Medical%20Review~Targeted%20Probe%20and%20Educate 

Some issues listed on these websites are the same or similar to each other’s, while some issues are unique to that MAC.  

Here are examples of issues MACs are reviewing, and some of their findings. If your organization provides these services, it might make sense for your compliance program to add these issues to your risk assessments, auditing, and monitoring plans. 

1. Submission of claims with the drug Lucentis (HCPCS code J2778) for eye injections.
   • Lacks medical necessity per policy. 
   • Lacks a covered indication. 
   • One month has not passed since last injection. 
2. Submission of claims with Hyaluronan or its derivatives (HCPCS codes J7318-J7332), which are used for intra-articular injections. 
   • Lacks medical necessity per policy. 
   • No functional improvement. 
   • Frequent cloned documentation. 
   • No evidence of failed conservative treatment prior to drug administration. 
   • Failure to use a standardized assessment tool to assess functional limitations. 
3. Wound Care (CPT codes 11042-11045). One MAC’s TPE review found that a lack of medical necessity was a significant reason for denying the claims.  This included lack of: 
   • Identification of wound location, size, depth, and stage supported by a drawing or photograph of the wound. 
   • Documentation of the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement. 
   • Documentation supporting the need of debridement. (i.e. wound is clean and free of necrotic tissue/slough). 
   • Medical record documentation supporting that a surgical excisional debridement was performed. 

As shown here, TPE information can be a valuable resource for compliance pros and departments to use in designing their audit plans. These TPE plan examples demonstrate specific areas of non-compliance that particular MACs observe for listed services. You can use this information to create your own checklist for compliance audits or proactive monitoring. 

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