Time to get your ducks in a row!

Published February 23, 2024

CMS has authorization to revoke Medicare billing privileges under certain conditions. Regulation 42 CFR §424.535(a)(8)(ii) states CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.

SNF service errors were determined to be the top driver of the overall Medicare Fee-for-Service improper payment rate. As part of the effort to lower the SNF improper payment rate, Medicare Administrative Contractors (MACs) will be reviewing a small number of claims from every Medicare-billing SNF in the country.

• 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.

The goal of the SNF 5-Claim Probe & Educate program is to assist SNFs in understanding how to bill appropriately under this new payment model and decrease the improper payment rate. So, it could evaluate any part of the payment process. Any claims for SNF services that took place on or after October 1, 2019 are eligible for the review, excluding those that contain a COVID-19 diagnosis. However, audits to date have generally been from dates following the recent MDS updates 10/1/2023.

Claims will be adjusted based on these audit findings, which can lead to potential lost revenue, and subject the provider to additional audits. The SNF will be offered education to address any errors identified, helping them to avoid future claim denials and adjustments.

Coretactics™ Experts in 5-Claim Probes Are Here to Help!

Coretactics 5-claim probe experts assist before, during & after your 5-Claim Audit. Reach out to us today.

• BEFORE: We can help prepare you for this audit in advance. Lack of proactive planning and training could increase negative audit results, like denial of claims.
• DURING: More importantly, we can help your facility during the audit to ensure proper documentation to support your claim is prepared accurately.
• AFTER: We also assist your facility in the aftermath of these audits. This critical step ensures risk areas are identified with a process improvement plan to reduce the risk of further claim denials and reductions.