On June 5, 2023, the Centers for Medicare & Medicaid Services (“CMS”) implemented a national skilled nursing facility (“SNF”) probe and educate program (“SNF P&E Program”). The SNF P&E Program is designed to reduce improper payments by identifying SNFs with high improper payment rates. Recently, CMS’s Comprehensive Error Rate Testing program projected an improper payment rate of 15.1% for SNF services in 2022, up from 7.79% in 2021. CMS determined that SNFs had the highest improper payment rate of all Medicare Fee-for-Service providers. The primary cause of SNF claim errors was found to be missing documentation.
PDPM Challenges
CMS emphasized that part of the reason for the significant increase in the improper payment rate appears to be a misunderstanding by SNFs about how to bill appropriately given the change from the Resource Utilization Group IV to the Patient Driven Payment Model (“PDPM”) for claims. The goal of the SNF P&E Program is to assist SNFs in understanding how to bill appropriately under this PDPM payment model and decrease the improper payment rate.
How Does the SNF P&E Program Work?
Under the SNF P&E Program, Medicare Administrative Contractors (“MACs”) will review five claims from every Medicare-billing SNF in the country. If issues are identified, the SNF will then be offered education to address the errors, helping them to avoid future claim denials and adjustments.
The SNF P&E Program will include one-on-one provider education after the completion of the five claim reviews. Each SNF will undergo only one round of review. Education offered will be individualized based on the claim review errors identified in the probe. Review results letters will detail the denial rational for each claim, as appropriate.
Time Period Covered
Any claims for SNF services that took place on or after October 1, 2019 are eligible for review except for those that contain a COVID-19 diagnosis, which will be excluded from the SNF P&E Program review.
Practical Takeaways
- Once a SNF is selected for the SNF P&E Program, the SNF should timely comply with all MAC requests.
- Depending on the outcome of the five-claim review, a SNF’s future claims may receive increased scrutiny after the audit.
- SNFs should be aware of common errors, such as missing documentation when submitting claims.
- SNFs should use the SNF P&E Program’s audit process to revisit internal claim compliance practices with their billing specialists and claims teams to help ensure timely improvement.
If you have questions or would like additional information about this topic, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
- Your regular Hall Render attorney.
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