CMS Initiates National SNF 5-Claim Probe and Educate Review beginning June 5 (SNF)

The Centers for Medicare and Medicaid Services (CMS) reissued transmittal instructions for Medicare Administrative Contractors (MACs) to perform a 5-claim probe and educate medical review on every skilled nursing facility in their jurisdiction. The purpose of this widespread review, which will be implemented in waves over the next year beginning June 5, 2023, is to lower the potential for SNF improper payment rates. Providers should be on the lookout starting in early June for medical records requests related to this program.  

The key elements of this project include:

• MACs will select 5 claims from each selected provider unless they are already under review or a very low volume provider.
• MACs will complete 1 round of probe and educate for each selected provider instead of the potential 3 rounds as instructed by the traditional targeted probe and educate (TPE) program.
• Education offered will be individualized based on the claim review errors identified in the probe.

This will be a pre-pay review unless a provider requests a post-pay review for hardship. If the MAC identifies an improper payment, it will adjust the individual claim payment, as appropriate, in addition to providing education – including the explanation for denial or payment adjustment. MACs may prioritize providers with errors in all five claims reviewed for the traditional and more extensive TPE program. Click here to read background information about this issue and for more details.