The Centers for Medicare & Medicaid Services (CMS) recently announced the start of the SNF (skilled nursing facility) 5-Claim Probe & Educate Review program. 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. The SNF will then be offered education to address any errors identified, helping them to avoid future claim denials and adjustments.
A new CMS webpage provides background information, Frequently Asked Questions (FAQs) and links to additional resources.
The 5-claim review strategy is like the current Targeted Probe and Educate (TPE) medical review strategy, in that it 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 as follows:
- MACs will review 5 claims from each SNF.
- MACs will complete one (1) round of probe and educate for each SNF.
- 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 SNF 5-Claim review process began on June 5, 2023, will be issued in waves over the next year, and will affect claims for services furnished after October 1, 2019. Claims containing the COVID-19 diagnosis will be excluded from the review. SNFs that are currently undergoing TPE will continue in that program and not the 5-Claim review. 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.