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Recent reports have highlighted the growing exasperation around the Skilled Nursing Facility 5-Claim Probe and Educate Review, initiated by the CMS in May 2023. The review mandates that all skilled nursing facilities participating in Medicare must submit audits on five Medicare Part A claims. These claims will be reviewed by Medicare Administrative Contractors (MAC) to highlight and reduce the number of future claim errors.  

The 5-Claim Probe and Educate Review program is geared towards aiding SNFs in navigating the complicated PDPM system so they can bill claims more accurately. SNFs with improper payment errors will receive basic education and claims adjustments to prevent future claim issues and adjustments. Naturally, providers must come to understand the potential impact of the Medicare claims review on their operational procedures. 

The CMS 5-Claim Probe and Educate Review program process and best practices

Below are five ways the 5-Claim Probe and Education program will impact healthcare providers, along with the potential solutions:

  1. Medicare administrative contractors (MACs) are set to pick out five claims from every SNF. These claims will cover SNF services billed on or after October 1, 2019. If possible, claims that involve a COVID-19 diagnosis will not be included. When reviewing claims for services during the Public Health Emergency (PHE) period (March 1, 2020 – May 11, 2023), MACs will consider any relevant flexibilities and waivers.

Best practice: Skilled nursing facilities need to notify their revenue cycle team, medical records, and billing office about this program and what’s expected. If they need further guidance, they can refer to the CMS website to access the list of COVID-19 flexibilities.

  1. In the CMS transmittal 12037, MACs are directed to choose a set of claims for upfront review before payment. If the provider is experiencing financial challenges, they may request the review after the payment.

Best practice: Facilities can ask for a review after payment. This route is for facilities with cash flow problems. Medicare claims are processed in the order they are received and paid subsequently. Therefore, if the initial claim is under review, subsequent claims will be handled once the first one is settled.

  1. Assessments will take place continuously, starting with the top 20% of providers who exhibit the most significant risk as determined by data analysis from MACs.

Best practice: SNFs need to be mindful of the risk level for their claims. It is advisable to download the Program for Evaluating Payment Patterns Electronic Report (PEPPER) and review it before submitting any claims. 

  1. If your MAC finds a payment error, the claim will either be corrected or declined.
A physician is discussing the latest CMS changes about the 5-Claim probe and educate review program with a team member.
In May 2023, the CMS mandated that all skilled nursing facilities participating in Medicare must submit audits on five Medicare Part A claims.

Best practice: Facilities must double-check their claims and ensure all the necessary details and documents are included. Common errors often involve missing physician signatures, missing notes on eligibility, needing more documentation to prove medical necessity, or incomplete initial certifications or recertifications. 

SNFs must respond promptly and accurately to information requests if they receive a payment error. Additionally, it is advisable to track medical record submissions and use the MAC portals to speed up the review process to ensure a timely receipt of information. 

If a facility can not respond on time, it may be possible to ask for an extension. The MAC should accept documentation arriving after 45 calendar days for valid reasons, such as natural disasters, business disruptions, or other exceptional circumstances.

  1. Should your MAC identify an incorrect payment, your facility will receive instructions about the specific billing concern. MACs will send out result letters to providers outlining the billing issues discovered and provide personalized claims education based on the identified errors.
  • For providers with an error rate of 20% or less, MACs will offer general education, allowing providers to request personalized one-on-one instruction if needed. The letter will indicate a specific phone number or contact person for providers to request education.
  • For providers whose error rate is higher than 20%, MACs will provide one-on-one education. MACs will contact these providers to schedule instruction if two or more claims have errors.
  • When providers opt for one-on-one education, MACs will provide education that includes details on the specific claims (like clinical details and reasons for denial) and allow providers to review claim decisions, ask questions, and receive constructive feedback to promote changes in behavior and enhance provider compliance.

Best practice: If claims lack proper support, SNFs should seek the available education for their revenue cycle team. This will identify the problems and how to resolve them. They can also audit other claims internally to gauge how extensive the issue might be. Depending on the findings, facilities can assess the necessary changes in their operational processes to prevent similar billing problems in the future.

SNFs should also be mindful of the limited sample size used for the review and understand that it might need to provide a clearer picture of the SNFs’ billing compliance status. For instance, one unsupported claim results in a 20% error rate, which can be misleading. 

Similarly, SNFs with no errors in the sample should not assume everything is fine. Therefore, providers should review patient assessments meticulously while identifying key PDPM payment indicators. In doing so, facilities can provide clear medical records to the CMS and show a coherent story about how the facility provides resident care.

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