All Skilled Nursing Facilities to Undergo 5-Claim Audit

Healthcare, Property & Casualty, Risk, Senior Living & Social Services

The Centers for Medicare & Medicaid Services has directed Medicare Administrative Contractors (MACs) to audit five Medicare claim submissions from every Skilled Nursing Facility (SNF) as part of a widespread review to lower the SNF improper payment rate. This is likely due to unintentional increases brought forth by Patient Driven Payment Model (PDPM).

The audit process is set to begin on June 5, 2023, and will be implemented in waves over the next year. As a SNF, be on the lookout for these record requests!

Key Elements of the Project

  • All MACs that review SNF Medicare claims will be included
  • MACs will select five claims from each selected provider
  • MACs will complete one round of probe and educate for each selected provider instead of the potential three rounds as instructed by the traditional TPE program
  • Education offered will be individualized based on the claim review errors identified in the probe

If the MAC identifies an improper payment, they will adjust the individual claim payment, as appropriate. Additionally, they will provide education with an explanation for denial or adjustment of payment.

Result of the Audit

Providers with 1/5 claims error rate will have to the option to receive 1:1 education. Providers with an error rate of 2/5 claims or more will need to schedule 1:1 education.

In the event a provider receives a 5/5 claims error rate, they will be prioritized for the Targeted Probe and Educate (TPE) program. TPE is designed to help providers improve quickly by identifying errors, in partnership with MACs.

How to Prepare

To ensure effective communication and avoid confusion, it is crucial to inform front office and/or business office team members about the audit and advise them to be vigilant for requests from CMS. It is important to distinguish these requests, so the team doesn’t believe they are junk mail or email spam.

Please share this important update promptly with the relevant individuals within the organization. Furthermore, here are some additional measures that can assist every skilled nursing facility in their preparation:

  • Assess the need for a proactive review/audit of Medicare claims submissions and supporting documentation to identify any potential errors in advance and submit for correction, if found
  • Incorporate this activity in your corporate compliance efforts
    • Add this topic to a committee meeting agenda: note as an auditing effort, report findings to committee, and rise to the board if warranted
  • Contact your financial advisor/partner to further prepare for the MAC audit

Key Takeaways:

All skilled nursing facilities will be required to undergo a Medicare claim audit. This audit process is set to begin on June 5, 2023, and will be implemented in waves throughout the year. The Centers of Medicare & Medicaid Services have given direction to MACs to audit five Medicare claim submissions for each skilled nursing facility. This is due to a widespread effort to lower the SNF improper payment rate.

As an SNF, there are ways to prepare. Please reach out to your M3 Account Executive or Risk Manager for further information.

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