Understanding TPE Audits: 3 Key Triggers That Put Hospices at Risk

For many hospices, the first sign of a CMS review comes in the form of a Targeted Probe and Educate (TPE) letter. While the process is intended to be educational, the financial and operational impact can be significant — especially when providers don’t understand what triggered the audit in the first place. 

At Hospice Quality Solutions, we help hospices prepare for and respond to TPE audits. Based on CMS data trends and firsthand experience, these are the top three triggers that most commonly lead to TPE selection — and how your organization can reduce its risk. 

1. Extended Lengths of Stay Without Clear Evidence of Decline 

CMS routinely flags hospices with average lengths of stay (ALOS) that are significantly longer than state or national averages — especially when clinical documentation does not consistently demonstrate ongoing decline. 

Why it matters: Hospice eligibility must be supported by clear, measurable evidence that the patient’s condition is worsening over time. Missing or vague clinical narratives, unchanged IDG notes, and lack of comparative detail across benefit periods are key risk indicators for TPE selection. 

Prevention Tip: Invest in Defensible Documentation Training for your hospice team. At Hospice Quality Solutions, we equip staff to document comparatively — clearly showing patient decline, supporting eligibility, and reducing denial risk. 

2. Diagnosis Patterns That Don’t Align With Typical Hospice Utilization 

Another major trigger involves diagnosis mix — especially high volumes of patients admitted under dementia, CHF, and Sarcopenia. While these conditions are legitimate hospice diagnoses, CMS and the MACs monitor for potential overuse or unsupported eligibility. 

Why it matters: Claims associated with non-cancer diagnoses are more likely to be reviewed because decline can be less linear and harder to document. When narratives, assessments, and care plans don’t show ongoing progression toward end of life, the MAC may flag those claims for TPE. 

Prevention Tip: Use interdisciplinary input — nursing, social work, and physician documentation — to capture a full picture of decline. Ensure narratives include objective data (PPS scores, weight trends, ADL changes) and link each clinical note to the overall hospice plan of care. 

3. High Routine Home Care Utilization or Billing Anomalies 

CMS monitors utilization patterns closely. A hospice that bills nearly all care at the Routine Home Care (RHC) level — with minimal GIP or CHC usage — may appear as an outlier, especially if documentation doesn’t justify the level of care. 

Why it matters: An unbalanced Routine Home Care (RHC) pattern can signal missed opportunities to adjust levels of care. For this measure CMS monitors transitions from RHC to GIP, not direct GIP admissions. When hospices miss signs of decline that justify higher-level care, patients often go to the ER and are hospitalized, driving higher Medicare costs. This also increases the provider's "burdensome discharge" rate (Hospice Care Index) when there are repeated hospitalizations followed by readmissions.

Prevention Tip: Strengthen your compliance through Level of Care Utilization Review and Support. We educate hospice teams on GIP, CHC, and respite criteria, analyze utilization trends, and pinpoint billing risks before they draw auditor attention. A well-balanced utilization profile protects your revenue and demonstrates audit readiness. 

TPE audits are not random — they are data-driven and pattern-based. By monitoring your hospice’s length of stay, diagnosis distribution, and utilization patterns, you can identify and correct risk areas before CMS does. 

At Hospice Quality Solutions, we specialize in helping hospices: 

• Identify audit triggers through internal risk assessments 
• Strengthen clinical documentation and staff education 
• Develop defensible audit response/prevention strategies 

Don’t wait for the letter to arrive. Proactive audit readiness protects your revenue, your reputation, and your mission of compassionate patient care. 

Need Help Assessing Your Audit Risk? 

Schedule a 15-minute Audit Readiness Review with our consultants at tclark@hospicequalitysolutions.com