Jun 16, 2026 · 26 min · 14 segments
Nearly every American hospital has at least one physician advisor. So, how does the physician advisor at your facility measure up? We reached out to longtime physician advisor Dr. Juliet Ugarte…
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Penny JeffersonHostJuliette Ugarte-HopkinsGuest
Deanna PetersonGuest
Frank CohenPanelist
Chuck BuckHost
It's not new, but it's becoming increasingly important as Medicare medical review continues to focus on claim accuracy, documentation support, and medical necessity and payment integrity.
CMS describes Targeted Probe and Educate as a program used by Medicare administrative contractors to identify providers and suppliers with high claim error rates, unusual billing patterns, or services with high national error rates.
The MAC reviews a targeted sample of claims supporting medical records, provides one-on-one education when errors are identified, and gives the organization time to improve before another round of reviews.
It is targeted, data-driven, and based on whether the claim and the medical record align.
Too often, the TPE is viewed as a billing issue, compliance issue, denials issue, or UR issue.
The documentation encoding decisions made before the claim is submitted often become the exact issues reviewed after the fact.
For inpatient cases, targeted probe and educate risk may involve whether the record supports the inpatient admission criteria continued hospitalization, medical necessity or services, procedures, diagnoses, treatment intensity, certification requirements, or level of care build.
And for outpatient cases, the risk may look different, but is equally important.
Reviews may focus on whether the encounter supports the service billed, whether required elements are present, whether diagnosis support medical necessity, or whether orders or signatures are complete, and whether the frequency and intensity of services is supported.
So whether we're talking about inpatient CDI, outpatient CDI, coding, UR, compliance, revenue cycle, the common thread is the same.
The strongest response to the TPE is not built during the education session after claims are denied.
It is built into the medical record in real time before the claim is submitted.
UR may identify that a stay or service is medically necessary, but if the provider documentation does not clearly explain why, the record may still be vulnerable.
CDI may recognize acuity, severity of illness, treatment intensity, or diagnostic uncertainty, but may not know there is a status or medical necessity concern being evaluated by UR.
Coding may assign the correct code, but if the record does not support the service setting, certification, or medical necessity, the claim may still be at risk at that point as well.
A case may have the correct inpatient order, a reasonable admission decision, and significant clinical acuity, but if the record does not clearly support why inpatient hospital care was required, why observation was not appropriate, or why the physician expected at the time of admission for the patient to be inpatient, that claim may be difficult to defend.
Likewise, an outpatient service may be clinically appropriate, but if required documentation elements are missing, the diagnosis does not support medical necessity or the encounter note does not support the service bill, the organization may still face denial risk.
It's not new, but it's becoming increasingly important as Medicare medical review continues to focus on claim accuracy, documentation support, and medical necessity and payment integrity.
CMS describes Targeted Probe and Educate as a program used by Medicare administrative contractors to identify providers and suppliers with high claim error rates, unusual billing patterns, or services with high national error rates.
The MAC reviews a targeted sample of claims supporting medical records, provides one-on-one education when errors are identified, and gives the organization time to improve before another round of reviews.
It is targeted, data-driven, and based on whether the claim and the medical record align.
Too often, the TPE is viewed as a billing issue, compliance issue, denials issue, or UR issue.
The documentation encoding decisions made before the claim is submitted often become the exact issues reviewed after the fact.
For inpatient cases, targeted probe and educate risk may involve whether the record supports the inpatient admission criteria continued hospitalization, medical necessity or services, procedures, diagnoses, treatment intensity, certification requirements, or level of care build.
And for outpatient cases, the risk may look different, but is equally important.
Reviews may focus on whether the encounter supports the service billed, whether required elements are present, whether diagnosis support medical necessity, or whether orders or signatures are complete, and whether the frequency and intensity of services is supported.
So whether we're talking about inpatient CDI, outpatient CDI, coding, UR, compliance, revenue cycle, the common thread is the same.
The strongest response to the TPE is not built during the education session after claims are denied.
It is built into the medical record in real time before the claim is submitted.
UR may identify that a stay or service is medically necessary, but if the provider documentation does not clearly explain why, the record may still be vulnerable.
CDI may recognize acuity, severity of illness, treatment intensity, or diagnostic uncertainty, but may not know there is a status or medical necessity concern being evaluated by UR.
Coding may assign the correct code, but if the record does not support the service setting, certification, or medical necessity, the claim may still be at risk at that point as well.
A case may have the correct inpatient order, a reasonable admission decision, and significant clinical acuity, but if the record does not clearly support why inpatient hospital care was required, why observation was not appropriate, or why the physician expected at the time of admission for the patient to be inpatient, that claim may be difficult to defend.
Likewise, an outpatient service may be clinically appropriate, but if required documentation elements are missing, the diagnosis does not support medical necessity or the encounter note does not support the service bill, the organization may still face denial risk.
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