The Centers for Medicare & Medicaid Services (CMS) recently announced the start of a new skilled nursing facility (SNF) 5 Claim Probe & Educate Review Program (SNF P&E Program). In an effort to reduce the SNF improper payment rate, Medicare Administrative Contractors (MACs) will review a small sample of claims from every Medicare-enrolled SNF in the country that submitted claims for services furnished after October 1, 2019. CMS has stated that each SNF will then be offered education to address any errors identified, with the purpose of helping them avoid future claim denials and adjustments. Claims containing a COVID-19 diagnosis will be excluded from the Program’s review.
The SNF P&E Program is being implemented primarily because, according to the Comprehensive Error Rate Testing (CERT) program, SNF service errors have roughly doubled from 2021 to 2022 and were determined to be the top driver of the overall Medicare Fee-for-Service improper payment rate. CMS maintains that part of the reason for the significant improper payment rate may be misunderstanding by SNFs regarding appropriate billing methods given the shift from the Resource Utilization Group (RUG) IV to the patient driven payment model (PDPM) for claims with dates of service on or after October 1, 2019. The stated goal of the SNF P&E Program, according to CMS, is to assist SNFs in understanding how to bill appropriately under this new payment model and decrease the improper payment rate.
Under the SNF P&E Program, similar to the current Targeted Probe and Educate (TPE) medical review program, SNFs will receive 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. Under this single round, MACs will review 5 claims from each SNF, and then education will be individually provided based on any claim review errors identified in the probe. Review results letters will detail the denial rationales for each claim, as appropriate.
As a practical consideration, once a SNF receives its request for records under the SNF P&E Program, the SNF should timely comply with all MAC requests. The SNF should treat the audit with care and consider available appeal rights in the case of claim denials because, depending on the outcome of the five-claim review, a SNF’s future claims may receive increased scrutiny following the audit. SNFs should be aware of common errors, such as missing signatures or documentation, when submitting claims. SNFs should take the opportunity to revisit internal claim compliance practices to further ensure timely improvement and future compliance.
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