The State of SNF Medical Review in 2025: Trends, Challenges, and Key Findings

The State of SNF Medical Review in 2025: Trends, Challenges, and Key Findings

Medical review of Skilled Nursing Facilities (SNFs) continues to be a focus of Medicare and Medicare Advantage oversight activities in 2025. With increased scrutiny from Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Unified Program Integrity Contractors (UPICs), providers are facing intensified audits and claim denial risk. The SNF 5-Claim Probe & Educate initiative, launched in 2023, remains a key tool in identifying documentation deficiencies and billing errors. In light of emerging medical review trends, SNFs must proactively mitigate financial risk and demonstrate a targeted commitment to reimbursement compliance. Let’s review recent SNF error trends…

Error rates and trends from recent SNF Medicare reviews show providers are struggling with documentation and billing compliance:

Palmetto GBA Jurisdiction J (AL, GA, TN), July – September 2024 = 27% error

Palmetto GBA Jurisdiction M (NC, SC, VA, WV), July – September 2024 = 10% error

Noridian Jurisdiction E (CA, HI, NV), October – December 2024 = 9% error

First Coast (FL) hasn’t issued specific error rates, but highlights top denial reasons from reach round of review

WPS Jurisdiction 5 (IA, KS, MO, NE) announced in January 2024 an error rate of 24.85%. While WPS has not publicly released further specific denial rates, J5 and J8 (MI, IN) combined host quarterly webinars to review findings and how to avoid them.

While CGS (OH, KY) and Novitas (AR, CO, LA, MS, NM, OK, TX, PA, MD, NJ, DE, DC) have not publicly released specific denial rates for recent SNF probe reviews, providers are encouraged to monitor MAC communications for updates and participate in educational sessions to enhance compliance with Medicare billing requirements.

In 2022, the Comprehensive Error Rate Testing (CERT) program reported a sharp increase in the improper payment rate for SNF services, rising to 15.1% from 7.79% in 2021. As we know, it was this alarming trend that prompted the launch of the SNF 5-Claim Probe & Educate Review in 2023 to address documentation and billing deficiencies. Unfortunately, the 2024 CERT report found another increase in the improper payment rate to 17.2%, amounting to approximately $5.9 billion in projected improper payments.

3 Common Denial Reason Trends & Recommendations to Avoid Them:

1. The documentation submitted does not support the level of service as shown on the claim. The HIPPS was recoded to reflect MDS changes supported by the documentation submitted.

Avoid this denial

• • Ensure that all charges are supported by documentation and MDS coding that meets requirements for accuracy and timeliness prior to submitting the final bill to Medicare. Review Proactive’s blog which provides recommendations and best practices related to Utilization Review & Triple Check Meetings.

2. Physician certifications/recertifications were incomplete and/or not obtained timely, and no documentation of delayed certification was submitted.

Avoid this denial

• • Ensure that staff responsible for this process understand signature requirements, along with the SNF certification/recertification technical elements. Review Proactive’s blog which details compliance standards for documenting Physician Certification/Recertification and provides a sample form and recommendations for strong facility processes.

3. The documentation submitted is insufficient for the services billed.

Avoid this denial

• • Ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered for the dates of service(s) billed, including the look-back of the Assessment Reference Date (ARD) supporting the HIPPS code billed. Check out Proactive’s ADR checklist as a resource to assist in collecting the documentation to submit to support a SNF claim and for guiding EMR monitoring compliance efforts. (Keep in mind, that all documentation requested in the ADR notice should be included in the submission packet.)

Another valuable resource released in December 2024 is the “Industry Segment-Specific Compliance Guidance for Skilled Nursing Facilities and Nursing Facilities” (the “Nursing Facility ICPG”) which may be used to assess existing compliance processes around “clean claims” billing. While the Nursing Facility ICPG is completely voluntary and nonbinding, it includes Medicare and Medicaid billing requirements as one of the four potential compliance risk areas for SNF, advising providers to conduct regular auditing and monitoring activities to confirm that coding accurately reflects residents’ characteristics and comorbidities.

Next Steps: Proactive assists Post-Acute providers (SNFs, Home Health Agencies, and Therapy Providers) in improving success rates under medical review through compliance audits, compliance program consultation and Medical Review support, including ADR response and appeals services. Contact us to learn how we can support your facility through the SNF 5 Claim Probe & Educate or other payer audits and overturn claim denials through appeals.