On May 4, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 13164, effective June 5, 2023. The purpose of the CR is to lower the skilled nursing facility (SNF) improper payment rate by having the Medicare Administrative Contractors (MACs) perform a 5-claim probe-and-educate medical review on every SNF in their jurisdiction.
CMS selects multi-state regional Medicare Administrative Contractors (MACs) to serve as the primary operational contact between the Medicare Fee-For-Service program and approximately 1.5 million healthcare providers enrolled in the program throughout the United States.
The CR is an attempt to increase comprehension of correct billing practices under the patient driven payment model (PDPM) by all SNF providers that bill Medicare. CMS is implementing a 5-claim probe-and-educate medical review strategy that allows for maximum outreach to all SNFs and offers provider-specific education, as necessary, in an attempt to prevent future improper payments.
Key elements of this probe-and-educate project include:
- All MACs that review SNF Medicare claims must participate
- Each MAC will select 5 claims for review from each selected provider
- MACs will complete one (1) round of probe and educate for each selected provider
- Education offered will be individualized based on the claim review errors identified in the probe
The CMS change request can be accessed here.
Obtain a list of MACs here: MACs-by-State_03.28.2023 (cms.gov).
Compliance Perspective
Issue
The Comprehensive Error Rate Testing (CERT) program for SNFs projected an improper payment rate of 15.1 percent in 2022, up from 7.79% in 2021. SNF service errors were determined to be the top driver of the overall Medicare Fee-for-Service improper payment rate. Part of the reason for the significant increase in the improper payment rate may be the change from the Resource Utilization Group (RUG) IV to the PDPM for claims with dates of service on or after October 1, 2019. The primary root cause of SNF errors was found to be missing documentation. Submitting claims to government healthcare programs that lack supporting documentation and therefore fail to meet criteria for the categories of services identified by the provider can be considered false claims.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims and completeness of supporting documentation. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare billing and completeness of supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, that thorough and accurate documentation supports the claim being submitted, and that any identified irregularities are immediately corrected before releasing the claim. Provide additional education on requirements for supporting documentation as needed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
