When Opinions Overrule Facts: The Unfair Reality of Medicare TPE Denials in Home Health

The Medicare Targeted Probe and Educate (TPE) program was intended to be a supportive process—an opportunity for agencies to improve documentation and ensure compliance through education. But for many home health providers, the reality feels far different. Too often, denials are being issued based not on the lack of skilled need, but on the auditor’s opinion that care was “not reasonable or necessary”—even in the presence of clear, objective evidence of skilled intervention.

Consider this: A licensed clinician documents measurable progress, identifies skilled interventions, and supports the care plan with validated assessment tools such as TUG scores, Tinetti results, or wound measurements. Yet, the chart is denied because the reviewer believes the patient could have improved without skilled care. No citation of CMS guidelines. No reference to the Conditions of Participation. Just subjective opinion—overriding clinical judgment and defensible documentation.

Let’s pause for a moment and put this into perspective: highly trained clinicians, who have spent hundreds of hours and thousands of dollars earning advanced degrees in nursing, physical therapy, or occupational therapy, are being overruled sometimes by individuals from entirely different clinical backgrounds. These denials don’t reflect gaps in care—they reflect a systemic issue where one discipline is allowed to discredit another without accountability or shared expertise.

This is not education. This is erosion of the trust clinicians place in the system.

TPE denials often ignore the complexity of home health patients—polypharmacy, cognitive decline, and functional impairments that make "simple" interventions truly skilled. Worse, agencies receive templated feedback with vague language and no true roadmap for correction, making it difficult to adjust practice or defend future care.

It's time for CMS and its contractors to return to the core principles of fairness, transparency, and clinical evidence. If education is the goal, then let’s educate. If compliance is the goal, then let’s clearly define what is expected. But let’s not allow subjectivity to deny patients the skilled care they deserve and clinicians the respect they've earned.

Have you received a denial with a questionable reason? Share the most unfair or vague denial rationale you've encountered in the comments. Let’s shed light on what’s really happening.