CMS Initiates National SNF 5-Claim Probe and Educate Review

The Medicare Administrative Contractors (MACs) have received revised instructions from the Centers for Medicare and Medicaid Services (CMS) regarding the evaluation of skilled nursing facilities (SNFs) within their respective jurisdictions. As part of this initiative, MACs will conduct a thorough review, known as a 5-claim probe and educate medical review, on every SNF. The primary objective behind this comprehensive assessment, which will be rolled out in phases over the next year starting from June 5, 2023, is to reduce the rate of improper payments in SNFs. Providers should anticipate receiving requests for medical records pertaining to this program, with the process set to commence in early June.
This project encompasses several important aspects, which are as follows:
  • All Medicare Administrative Contractors (MACs) responsible for reviewing SNF Medicare claims will be involved.
  • MACs will choose five (5) claims from each selected provider for review, unless the provider is already under review or operates at a very low volume.
  • Instead of the typical three (3) rounds prescribed by the  targeted probe and educate (TPE) program, MACs will conduct a single round of probe and educate for each selected provider.
  • The education provided will be tailored to address the specific errors identified during the claim review process.
For this initiative, a pre-pay review process will be implemented, unless a provider specifically requests a post-pay review due to hardship. In cases where the Medicare Administrative Contractor (MAC) identifies an improper payment, appropriate adjustments will be made to the payment for the individual claim. Additionally, the MAC will offer educational resources, which will include an explanation for denial or payment adjustment. Providers who have errors identified in all five claims reviewed may be given priority for participation in the traditional and more extensive targeted probe and educate (TPE) program.
CMS will issue provider education content related to this national review program through the MLN Connects® newsletter.
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