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TPE Results

July - September 2026

Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education to providers during, and upon completion of, each round of review.

The information below describes Targeted Probe and Educate (TPE) results for Part A providers.

Probes Completed

Results Kentucky Ohio
Probes completed 25 63
Providers compliant after round completion 23 56
Providers non-compliant after round completion 2 8
Providers with non-response to ADRs 4 20

Inpatient Hospital – Round 1

Results Kentucky Ohio
Probes completed 2 18
Providers compliant after round 1 completion 2 14
Providers non-compliant after round 1 completion 0 4
Providers with non-response to ADRs 1 10

Hospital Round 1

Top Findings

  1. Documentation submitted doesn’t support medical necessity as listed in coverage requirements.
  2. Non-response to ADRs.
  3. Provider didn’t submit all records requested.

Inpatient Hospital – Round 2

Results Kentucky Ohio
Probes completed 0 2
Providers compliant after round 2 completion 0 0
Providers non-compliant after round 2 completion 0 2
Providers with non-response to ADRs 0 0

Hospital Round 2

Top Findings

  1. Documentation submitted doesn’t support the level of care reported on the claim; therefore, the coding on the claim changed.
  2. Provider didn’t submit all records requested.

Inpatient Psychiatric – Round 1

Results Kentucky Ohio
Probes completed 1 3
Providers compliant after round 1 completion 0 3
Providers non-compliant after round 1 completion 1 1
Providers with non-response to ADRs 0 0

Inpatient Psychiatric Facility 1

Top Findings

  1. Documentation submitted doesn’t support medical necessity as listed in coverage requirements.
  2. Documentation submitted doesn’t include the required certifications or recertifications.

Inpatient Rehabilitation Facility – Round 1

Results Kentucky Ohio
Probes completed 3 4
Providers compliant after round 1 completion 2 4
Providers non-compliant after round 1 completion 1 0
Providers with non-response to ADRs 0 1

Inpatient Rehabilitation Facility 1

Top Findings

  1. Documentation doesn’t include a preadmission screening.
  2. Non-response to ADRs.
  3. Documentation doesn’t support that the patient can actively participate in and benefit significantly from the intensive rehabilitation therapy program.

Skilled Nursing Facility - Round 1

Results Kentucky Ohio
Probes completed 14 29
Providers compliant after round 1 completion 14 28
Providers non-compliant after round 1 completion 0 1
Providers with non-response to ADRs 2 8

SNF 1

Top Findings

  1. Documentation submitted doesn’t support the level of care reported on the claim; therefore, the HIPPS code changed.
  2. Non-response to ADRs.
  3. Documentation submitted doesn’t support that SNF services are medically reasonable and necessary for the treatment of the beneficiary's illness or injury.

Skilled Nursing Facility – Round 2

Results Kentucky Ohio
Probes completed 5 7
Providers compliant after round 2 completion 5 7
Providers non-compliant after round 2 completion 0 0
Providers with non-response to ADRs 1 1

SNF 2

Top Findings

  1. Documentation submitted doesn’t support the level of care reported on the claim; therefore, the HIPPS code changed.
  2. Documentation submitted doesn’t include the required certifications for the SNF stay.
  3. Documentation submitted doesn’t support that SNF services are medically reasonable and necessary for the treatment of the beneficiary's illness or injury.

Education
Provider education sessions are available via webinar, teleconference, or other methods:

  • CGS offers an individualized education session to providers with a moderate to high error rate. This includes the opportunity to discuss errors identified and address any questions or concerns.
  • Providers may also request an individualized education session at any time.
  • Widespread education sessions are posted on the Part A Calendar of Events.

Please email questions or education requests to: J15AMREDUCATION@cgsadmin.com.

Next Steps
At the completion of TPE round 1/2, providers identified as non-compliant advance to TPE round 2/3 at least 45 days from the 1:1 post-probe education call completion date. You may request education at any time even if you aren't elected for TPE. CGS encourages providers to request education, conduct self-monitoring based on our Medical Review Activity Log, and use other self-service tools available on our website or Comparative Billing Reports (CBRs) in the myCGS portal.

References

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