Is Medicare’s TPE Program Fulfilling Its Promise—or Just Meeting a Quota?

By Melanie Cobb PT, DPT, CSCS, COQS, BCHH-C

Home Health Consultant & Compliance Advocate

The Medicare Targeted Probe and Educate (TPE) program was originally introduced with a seemingly noble purpose: to educate providers and reduce claim errors through collaboration, not punishment. But for many home health agencies and consultants across the country, the experience tells a different story—one where education takes a backseat to audit volume, and where “targeting” feels more like unfair scrutiny than meaningful guidance.

A Program That Misses the Mark

The Centers for Medicare & Medicaid Services (CMS) designed the TPE initiative to focus on providers with high denial rates or unusual billing patterns. While this may sound reasonable, the reality is far more problematic.

Agencies often face TPE denials based on subjective interpretations of clinical documentation—particularly around Face-to-Face (F2F) encounter notes, homebound status, and skilled need. Rather than educating clinicians on how to improve documentation, many MAC reviewers simply issue blanket denials with vague or inconsistent rationales. Some reviewers even disregard supporting evidence found throughout the medical record, narrowly focusing on isolated phrases in a physician note. My favorite? "Clinician working on increasing gait distance, activity and endurance tolerance not reasonable, necessary and at a level of complexity to require skilled intervention"; when I reviewed the chart a 3rd time, the therapist had only worked on increasing distance in 1 out of the 6 visits that were audited. Make it make sense.

Education or Audit Quota?

One of the most glaring concerns is that the “educate” portion of TPE has become more of a formality than a meaningful opportunity for collaboration. Agencies report receiving generic education calls, with little to no specific feedback about the denied claims. In some cases, consultants and clinicians are presented with scripted responses rather than case-specific insight.

This leads to an unavoidable question: Is the true goal of TPE to improve provider performance—or simply to meet CMS audit quotas?

When agencies receive three rounds of denials, even after making documentation improvements, it suggests that success is measured less by quality improvement and more by volume of probe cycles completed.

Wrongful Denials Harm More Than Agencies

The most damaging consequence of these denials is their effect on patient care. Patients with chronic or complex conditions are often denied services under the incorrect presumption that their condition is “stable” and no longer requires skilled intervention. But Medicare policy clearly supports coverage for maintenance therapy and chronic condition management when a skilled clinician is required.

In turn, agencies may begin avoiding higher-risk patients altogether, fearing that legitimate care could trigger an audit and lead to non-payment. This is the exact opposite of what the home health benefit was intended to accomplish—and it directly impacts access to care for the elderly and disabled populations.

Where Do We Go From Here?

It’s time for CMS and its Medicare Administrative Contractors (MACs) to refocus the TPE program on its original intent: education. That means:

• Requiring reviewers to provide specific, case-based feedback -- examples would be helpful!

• Aligning denials with actual Medicare policy, not personal interpretation; Perhaps a Therapist review the therapy portion?

• Tracking the outcomes of education sessions—not just audit cycles

• Allowing providers to collaborate with reviewers, rather than be penalized without recourse

  
  

As home health consultants, we’re not asking for leniency—we’re asking for fairness. We believe in accountability and quality care. But when education is replaced with bureaucracy and collaboration is replaced with quotas, both providers and patients lose.