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SNF 5-Claim Probe Coming - What You Need To Know

In a recent update, CMS has announced that effective on June 5, 2023, CMS will implement a 5-Claim Probe and Educate Review for all Skilled Nursing Facilities. CMS identifies in Transmittal 12037 (Found Here) that this is in direct response to the Comprehensive Error Rate Testing (CERT) program identifying an increase in improper payment rate of 15.1% in 2022 as a direct result of the change from RUG IV to PDPM on October 1, 2019.

This project will be conducted by Medicare Administrator Contractors (MAC). MACs will select 5 Medicare A claims to be reviewed from each SNF provider on a pre-pay basis. When selected for review, each individual claim will not be paid until reviewed by the MAC and claims will be adjusted if improper payment is identified. Facilities will be able to individually request a post-pay review for hardships.

The key elements of this project include:

  • All MACs that review SNF Medicare claims.

  • MACs will select five (5) claims from each selected provider

  • MACs will complete one (1) round of probe and educate for each selected provider instead of the potential three (3) rounds as instructed by the traditional TPE program

  • Education offered will be individualized based on the claim review errors identified in the probe

CMS has identified that the primary reason for SNF errors in prior reviews is missing documentation and that they will prioritize this review to begin with the top 20% of providers who show the highest risk based on MAC data analysis. Eventually, all SNFs will receive the audit requests from the MAC. It is imperative that SNFs have a process in place to be prepared to receive these requests, gather records, and submit them in a timely and accurate manner.

It is important that accurate records get sent in initially to avoid any potential denials, timely release of claim payment, and avoid the potential for your facility to be selected for additional reviews in the TPE program.

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