Skilled Nursing Facility 5-Claim Probe and Educate Review

June 8, 2023

CMS PROGRAM INTEGRITY INITIATIVE

Today’s Action:

The Centers for Medicare & Medicaid Services (CMS) has recently announced the start of the SNF (skilled nursing facility) 5 Claim Probe & Educate Review program. As part of the effort to lower the SNF improper payment rate, Medicare Administrative Contractors (MACs) will be reviewing a small number of claims from every Medicare-billing SNF in the country. The SNF will then be offered education to address any errors identified, helping them to avoid future claim denials and adjustments.

The Comprehensive Error Rate Testing (CERT) program projected an improper payment rate of 15.1 percent for SNF services in 2022, up from 7.79% in 2021. SNF service errors were determined to be the top driver of the overall Medicare Fee-for-Service improper payment rate. Part of the reason for the significant increase in the improper payment rate may be misunderstanding by SNFs about how to bill appropriately given the change from the Resource Utilization Group (RUG) IV to the PDPM (patient driven payment model) for claims with dates of service on or after October 1, 2019. The goal of the SNF 5 Claim Probe & Educate program is to assist SNFs in understanding how to bill appropriately under this new payment model and decrease the improper payment rate.

The proposed 5 claim strategy will extend the broadest reach to all SNFs. Similar to the current Targeted Probe and Educate (TPE) medical review strategy, the SNF 5 Claim Probe & Educate Program will include 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.

• MACs will review 5 claims from each SNF.
• MACs will complete one (1) round of probe and educate for each SNF, not the potential three (3) rounds that may occur in the traditional TPE program.
• Education offered will be individualized based on the claim review errors identified in the probe. Review results letters will detail the denial rationales for each claim, as appropriate.

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

SNF 5-Claim Probe and Educate Review Frequently Asked Questions (FAQs)

1. Why did CMS develop the SNF 5-Claim Probe and Educate Review?

The payment model for SNF services changed from the Resource Utilization Group (RUG IV) to the Patient Driven Payment Model (PDPM) for dates of service after October 1, 2019. CMS believes that misunderstanding by SNFs about how to bill appropriately given the change in payment model may have contributed to the increase in the SNF improper payment rate. CMS would like to decrease the improper payment rate and improve provider understanding of the PDPM by providing education based on individual claims errors.

2. Where can providers access resources related to the PDPM?

Details regarding the PDPM can be found on the CMS website at https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/pdpm.

3. What is the look-back period for the SNF 5-Claim Probe and Educate Review?

Any claims for SNF services that took place on or after October 1, 2019 are eligible for the review except for those that contain a COVID-19 diagnosis, which will be excluded from this review.

4. What happens if a SNF is currently undergoing Targeted Probe and Educate (TPE)?

SNFs that are currently undergoing TPE will continue in that program. Also, SNFs that have recently undergone and passed TPE will not qualify for the SNF 5-Claim Review for one year from the date that they were released from TPE review.

Visit the MLN Article (PDF) for more information.