On June 5, 2023, the Centers for Medicare and Medicaid Services (CMS) initiated a Skilled Nursing Facility (SNF) 5-Claim Probe and Education Review program. As part of the effort to lower the SNF improper payment rate, Medicare Administrative Contractors (MACs) are reviewing a small number of Medicare Part A 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.
AHCA previously
provided information about a
new webpage CMS established for this program where providers could locate background information, Frequently Asked Questions (FAQs), and links to additional resources.
Since implementation, AHCA has received inquiries from members that the 5-claim review letters they have received from their MAC does not offer a post-pay option while the CMS instructions to the MACs (
CR 13164) include the requirement.
“Contractors shall select a sample of 5 claims for prepayment review (with occasional post-pay, if requested by the provider due to
financial burden) from the universe of claims for all SNFs that submit claims for Medicare SNF services within the contractor's
jurisdiction.”
AHCA sought clarification from CMS and the Agency responded indicating that, “the CR allows MACs the discretion to conduct post pay when it is requested by the provider and the MAC determines that there is support for such a request.”
In addition, the CMS official indicated that the CR also indicates the MACs can grant extensions of the submission timeframe in certain situations per the following instruction:
The MAC should accept documentation received after 45-calendar days for good cause. Good cause means situations such as
natural disasters, interruptions in business practices, or other extenuating circumstances that the contractor deems good cause in
accepting the documentation.
AHCA members can contact
Dan Ciolek with questions or issues related to this program.
Background
The 5-claim review strategy is like the current Targeted Probe and Educate (TPE) medical review strategy, in that it will include one-on-one provider education at the completion of a small sample of claim reviews. However, instead of the one-to-three rounds of review a provider receives through TPE, each SNF will undergo only one round of review as follows:
- MACs will review five claims from each SNF.
- MACs will complete one round of probe and educate for each SNF.
- 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 review process which began on June 5, 2023, will be issued in waves over the next year, and will affect claims for services furnished after October 1, 2019. Claims containing the COVID-19 diagnosis will be excluded from the review. SNFs currently undergoing TPE will continue in that program, not the 5-Claim review. 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. A summary of the 5-Claim Review is also provided in the
CMS MLN Matters MM13164 article.