Important CMS Update: 5/11/2023
CMS just directed their MACs to conduct a 5-claim PROBE on every SNF in their jurisdiction beginning in June.
The goal of this initiative is to lower the improper payment rate to SNFs.
SNF errors were found to be the top driver of the overall Medicare improper payment rate — 2022 reviews identified a 15.1% SNF claim error rate; up from 7.79% in 2021.
Key elements include:
· MACs will select 5 claims from each provider for pre-payment review
· MACs will begin with the top 20% of providers who show highest risk based on data analysis (we recommend facilities review their PEPPER Reports:https://pepperfile.cbrpepper.org/#)
· MACs will complete one round of review for each provider
· For providers with error rates of 20% or less, MACs will provide education with the option for 1:1 education
· For providers with error findings >20%, MACs will schedule 1:1 education
· The MAC will report probe results on a monthly report submitted to the CMS RAC Data Warehouse. The report will include number of providers with 1, 2, 3, 4, and 5/5 errors, top 10 error reasons, and method of educational interventions
The focus of these audits is Medicare Claims.
We strongly recommend facilities implement a strong TRIPLE CHECK System to ensure the accuracy of their claims prior to billing.
Triple check should focus on accuracy of key reimbursement areas:
· GG scores: interdisciplinary documentation from Rehab and Nursing
· Diagnoses: are still active and have direct relationship on current care
· BIMS and PHQ-9: date of completion is on or before ARD date
· Swallowing issues: are care-planned
· Dates and Signatures: are timely as per regs
As a reminder, Enhance Therapies offers a comprehensive claims management service.
The primary root cause of the SNF errors was found to be missing documentation!
Claim submission must be accurate and complete to avoid denials!
If you receive a PROBE, or would like to hear more information about our comprehensive claims service, please email us at:
