MACs have begun rolling out the mandated 5-Claim Probe and Educate audit and will eventually review claims for every eligible SNF in their jurisdiction. SNF certifications and recertifications are important elements of SNF Medicare stay compliance and will be considered as part of this review. In this blog, we’ll delve into the essential aspects of the SNF certification / recertification process, and share guidance and insights for assessing your process and ensuring compliance.
According to the most recent Comprehensive Error Rate Testing (CERT) report released by the Centers for Medicare & Medicaid Services (CMS), SNF improper payment rates nearly doubled since the 2021 report. Of the claims identified with error, inadequate or missing documentation for Physician’s Certifications/Recertifications accounted for over 31% of errors contributing to these improper payments. Consistent with these findings, SNF certification/recertification accuracy continues to rank among the top errors Proactive observes in Medicare compliance reviews.
5 Items to Include in Your SNF Certification/Recertification Compliance Check-Up:
- Process management
- Ensure facility staff delegated to oversee the Certification/Recertification process have a clear understanding of CMS guidance; unfortunately, it is not uncommon to find staff that were trained by a predecessor who did not fully understand the regulation or used a faulty form; Check out our blog on required criteria and avoiding common errors
- Identify and train a back up person responsible for managing the process in the absence of the primary designee
- Collaborate with primary physicians/NPPs to identify the preferred method of obtaining documentation and signatures in a timely manner
- Establish a system upon admission to begin the initial cert process
- Create a tracking system for timely completion of recertification dates
- Take advantage of physician visits to obtain SNF certification/recertification documentation when possible
- Include certs/recerts in your triple check meeting
- Date Accuracy
- Initial Certification and the first Recertification are based on the admission to skilled care date
- Initial Certification is required on admit or as soon thereafter as is practicable
- First Recertification must be signed and dated by the physician/NPP on or before day 14 of the skilled stay
- Subsequent recertifications are required within 30 days of the signature date on the prior certification
- The physician must date each certification and recertification for the date he or she signed the form–backdating is not allowed
- If the physician signed the certification with a date after the due date, a delayed certification is needed
Examples: Physician Certification/Recertification Due Dates
- Who is allowed to sign the certification/recertification?
- Must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, a physician assistant) who is working in collaboration with the physician, when permitted under the scope of practice for the State.
- The physician extender cannot sign the certification when there is a direct or indirect employment relationship with the facility.
- For additional detail, see 424.20, Requirements for posthospital SNF care (e) Signature, which includes type of employment relationships
- Type of Physician / NPP Signature Accepted
- Legible signature with credential. If illegible, a signature key should be provided in medical review.
- Fax signatures. If needed, the time stamp on the fax may be used to acknowledge the signature date
- Electronic signatures are acceptable, but be sure to follow a defined facility policy and ensure that e-signatures are timestamped
- Rubber stamp signatures are not accepted without a valid disability
- Who completes the facility Certification/Recertification form?
- SNF staff can complete the summary of skilled care, estimated time period, and post-SNF plans
- The physician / NPP must review and indicate approval via dated signature
- Facility staff should not assign the physician signature date
- Facility staff should not prepopulate the recertification due date(s)
- Keep in mind, no specific form is mandated to be used for Physician Certification/Recertification. SNFs can opt to use a form, physician notes, or other physician records, but the documentation must include all required components and meet timeliness criteria.
According to the SNF 5-Claim Probe and Educate Review Transmittal 12037, MACs shall prioritize providers with 100% claims error for TPE review. Generally speaking, if there is an issue with one SNF certification, the issue likely applies to multiple claims. In the event of a claim denial due to Certification issues, SNFs do have the right to appeal with a delayed Certification. However, striving for consistent compliance from the outset is definitely preferred.
Take a look at our sample Physician Certification and Recertification form to assist in your process refresh. Contact Proactive to schedule a remote Medicare compliance audit, PDPM validation review, or to learn more about Medical Review support services including ADR preparation, pre-submission ADR previews, and Medicare appeals management.
Written By: Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services
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