Skilled Nursing Facility 5 – Claim Probe and Educate Review

Skilled Nursing Facility 5 – Claim Probe and Educate Review

The SNF 5-Claim Probe & Educate Review is the recently announced initiative by CMS (Centers for Medicare & Medicaid Services). Medicare Administrative Contractors (MACs) received reissued transmittal instructions to review a small number of claims from every Medicare-billing SNF in the country. The purpose of this widespread review is to lower the SNF improper payment rate. The SNF will then be educated to address any errors identified, helping them to avoid future claim denials and adjustments. The SNF 5-Claim Probe & Educate program is designed to assist SNFs better understand billing under the Patient Driven Payment Model (PDPM)

As Per CMS, the Comprehensive Error Rate Testing (CERT) program for SNFs projected an improper payment rate of 15.1%, up from 7.79% in 2021. SNF service errors were determined to be the top contributor of the overall Medicare Fee-for-Service improper payment rates. This significant increase in the improper payment rate may be attributed to the misunderstanding by the SNFs regarding how to appropriately bill since the change from the Resources Utilization Group (RUG) IV to the PDPM (patient driven payment model) for claims with date of service on or after October 1, 2019. The primary root cause of SNF error was found to be missing documentation.

CMS asserts that the 5 Claim Probe & Educated review is an attempt to increase comprehension of correct billing practices.  The 5 Claim Probe & Educate medical review strategy permits maximum outreach to all SNFs and provider provider-specific education, as necessary, to prevent future improper payments. The 5-Claim Probe & Educate Review is similar to the current Targeted Probe & Education (TPA) medical review strategy, as it will includes one on one provider education at the completion of a small sample of claim reviews. However, instead of the 1-3 rounds of review a provider receives through TPE, each SNF will undergo only 1 round of review. The SNF 5-Claim Review audit will consist of the following steps-

  • MACs will review 5 claims from each SNF
  • MACs will complete one round of probe and educate for each SNF
  • Education offered will be individualized based on the claim review errors. Review result letters will outline the denial reasoning for each claim as appropriate.

The SNF 5-Claim Review audit will begin on June 5th, 2023, and will affect claims for services furnished after October 1st, 2019. Claims containing COVID-19 diagnosis will be excluded from the review.

5 – Claim Probe and Educate Review

The following are the specific instructions provided by CMS o the MACs for the review impacting providers:

  1. How to select Samples & Implement the Review Process

  • Macs to select a sample of 5 claims from the plethora of claims from all SNFs that submit claims for Medicare SNF services within the MACs jurisdiction.
  • MACS will implement the SNF 5-Claim reviews on a rolling basis beginning with the top 20% of providers that show the highest risk based on MAC data analysis.
  • Contractors will exclude providers under review by other contractors.
5 – Claim Probe and Educate Review

Top root cause for skilled nursing facility

  1. Provider Notification of Review Results & MAC Provider Education Responsibility

  • Detailed result letters will be sent out once an individual provider’s 5-Claim sample is completed, this includes sending result letters to providers with no error findings as well. The minimum expectation of CMS is detailed letters to include individualized, claim by claim denial rationales (this may be based on CMS provided denial dispositions), and contractors are encouraged to include written clinical details which must be discussed during the one-on-one education.
  • Providers with an error rated of 20% or less: MACs will provide widespread education with the option to receive one-on-one education.
  • Providers with error rate more than 20%: MACs will offer one-one-one education, they will contact the provider to schedule education if 2 or more claims are in error.
  • MACs will notify providers at the beginning of every teleconference that the discussion may be monitored by CMS.
  1. Other Technical Guidance

  • Language informing the provider that they can request additional time to respond to the ADR if they are experiencing burden will no longer be included in the provider notification letters.
  • Documentation received after 45 days can be accepted for good cause. Good cause means situations like natural disasters, interruption in business practices or other extenuating circumstances.
  • The round of review will be closed if 5 claims are not billed within 12 months.
  • Macs will use their easily curable error process in case reviewers identify an easily curable error and have a mechanism for contacting a provider’s representative that may be able to provide the compliant documentation.
  • Claims with dates of service during the PHE only, MACs shall exclude claims containing COVID-19 diagnosis.
  • MACs can apply any applicable flexibilities & waivers when reviewing claims for dates of service after March 1st, 2020, until the end of the Public Health Emergency.
  1. Instructions Regarding Providers with 5/5 Claims in Error

  • MAC will prioritize for TPE review for providers who at the conclusion of the SNF 5 Claim Review have 5/5 claims in error, if SNF is included in their existing Medical Review Strategy

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