SNF Meetings– UR & Triple Check Essentials
According to a recent Agency Financial Report released by the Department of Health and Human Services (HHS), the primary reasons for SNF payment error include (1) missing or insufficient documentation to support the skilled coverage criteria requirements and (2) missing or insufficient documentation to support the required component(s) for the billed code. Briefly, this means that documentation was not present (or not returned with the ADR) to validate the condition(s), care or service(s) provided in the SNF. The Utilization Review (UR) and Triple Check Meetings are essential activities to reduce the risk of payment error in your facility. This week’s blog reviews key components of these meetings to facilitate SNF billing accuracy and medical review success.
Providers need a reliable process to systematically ensure billing accuracy. Implementing a robust Utilization Review and Triple Check process serves as the cornerstone for compliance and services several functions: helping to mitigate billing errors and irregularities, enabling self-identification of mistakes, and identifying potential areas of risk.
Organizations that fail to perform systematic Utilization Review and Triple Check meetings run the risk of incomplete or incorrect documentation in support of claims and creates risk for the facility and team members attesting to MDS and UBO4 accuracy as described below.
MDS Section Z:
| I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf. |
UB04:
| · The submitter of this form understands that misrepresentation of falsification of essential information as requested by this form, may serve as the basis for civil monetary penalties and assessments and may upon conviction include fines and/or imprisonment under federal and/or state law(s). · Submission of the claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard of misrepresent or conceal material facts. · Physician’s certifications and re-certifications are on file. |
Audits are currently underway for the Skilled Nursing Facility 5-Claim Probe and Educate Review. It’s no longer a matter of if you will face medical review, but when. While audits have already been initiated for the top 20% of providers found to be at greatest risk of SNF Claim inaccuracy, this pre-pay review is coming to facilities nationwide. Take time now to review your Utilization Review & Triple Check processes in order to ensure compliance with regulations, promote quality care and optimize reimbursement accuracy .
For more information on achieving effective and efficient facility meetings, join our 4-week webinar series, Getting Together: Meetings That Work with UR/Medicare and Triple Check Meetings covered during the December 6, 2023 session. Contact Proactive to schedule assistance in developing improved meeting processes through meeting monitoring/audits, education and the development of policies-procedures and forms to drive efficiency and substantive meetings.
Stacy Baker, OTR/L, RAC-CT, CHC
Director of Audit Services
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