CMS: SNF 5-CLAIM PROBE & EDUCATE REVIEW
May 9th, 2023
CMS: SNF 5-CLAIM PROBE & EDUCATE REVIEW
Attention: Implementation date - June 5, 2023
In an attempt to increase comprehension of correct billing practices under PDPM by all SNF providers that bill Medicare, and to prevent future improper payments, CMS is implementing a 5-claim Probe and Educate Medical Review Strategy.
BACKGROUND
The Comprehensive Error Rate Testing (CERT) program for SNF’s projected an improper payment rate of 15.1% in 2022, up from 7.79% in 2021.
SNF service errors were at the top of overall Medicare fee-for-service improper payment rates. Part of the reason for the significant increase may be the transition from RUG IV to PDPM. The primary root cause of SNF errors was found to be missing documentation.
KEY PROBE ELEMENTS INCLUDE
- All MACs
- MACs will select 5 claims from each selected provider
- All SNFs will be audited beginning with the top 20% of providers that show the highest risk data analysis
- MACs will complete 1 round of Probe & Educate instead of the usual 3 rounds Education offered will be individualized based on claim review errors identified in the probe
The complete transmittal notification can be found here.
SOURCE: https://www.cms.gov/
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and Appeals Management, bblatt@preftherapy.com.
