Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

Today, May 4, 2023, CMS issued Transmittal 12015 with same title as this blog.

The Comprehensive Error Rate Testing (CERT) program for SNFs (skilled nursing facility) projected an improper payment rate of 15.1 percent 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 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 primary root cause of SNF errors was found to be missing documentation.

This CR is an attempt to increase comprehension of correct billing practices under the PDPM by all SNF providers that bill Medicare. CMS is implementing a 5-claim probe and educate medical review strategy that allows for maximum outreach to all SNFs and offers provider-specific education, as necessary, in an attempt to prevent future improper payments.

The key elements of this project include:

            • All MACs that review SNF Medicare claims

            • MACs will select 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.

This CR does not involve any legislative or regulatory policies.

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