A new CMS web page is now available devoted to the SNF 5-Claim Probe and Educate audit initiated June 5, 2023 as part of the effort to lower the SNF payment error rate.  The webpage includes additional information and FAQs on what to expect as the review has gotten underway in June and will affect claims for services furnished after October 1, 2019—with claims containing the COVID-19 diagnosis excluded. Similar to the current Targeted Probe and Educate (TPE) medical review strategy, the SNF 5 Claim Probe & Educate Program will include one on one provider education at the completion of a small sample of claim reviews. However, instead of the 1-3 rounds of review a provider receives through TPE, each SNF will undergo only 1 round of review.

    • MACs will review 5 claims from each SNF.
    • MACs will complete one (1) round of probe and educate for each SNF, not the potential three (3) rounds that may occur in the traditional TPE program.
    • Education offered will be individualized based on the claim review errors identified in the probe. Review results letters will detail the denial rationales for each claim, as appropriate.
    • SNFs that are currently undergoing TPE will continue in that program. Also, SNFs that have recently undergone and passed TPE will not qualify for the SNF 5-Claim Review for one year from the date that they were released from TPE review.

What documents will be requested on the ADR?

    • Hospital discharge/transfer summary
    • Physician certification for the need for skilled daily post-hospital care in a skilled nursing facility
    • All physician’s orders, nurse’s notes, rehab orders/notes, and actual minutes of rehab therapy to support the billing and look back periods under review
    • Any additional documentation to support medical necessity of services for the billing and look back periods under review. Submitted documentation should include any notes related to the ARD(s) and look back periods can extend back as far as 30 days prior to the billing period under review
    • Please submit all documentation as required in the LCD or NCD if applicable

Ensure your ADR submission is complete and accurate. Contact Proactive for assistance in successfully managing your facility’s response to the SNF Probe.

Written By: Amie Martin, OTR/L, CDP, CHC, RAC-CT, MJ

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