Earlier this year, CMS announced the start of the Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review program. This is in response to a 15.1% increase in improper payments for 2022 services, as projected by the Comprehensive Error Rate Testing (CERT) program—likely driven by the change in payment model from Resource Utilization Group (RUG) IV to the PDPM (Patient-Driven Payment Model) in October 2019.

As a result, CMS has directed all Medicare Administrative Contractors (MACs) to conduct a pre-payment review of five SNF claims for all providers nationwide, with few exceptions. Unless your SNF is already under medical review or is considered a low-volume provider (fewer than five Part A claims per calendar year), you will be subject to the Targeted Probe and Educate (TPE) program and may have already received notification from your MAC.

What can you do now to prepare your staff for this new program? We’re glad you asked! Professionals at FORVIS recommend the following five action areas:

1. Prepare Always

• Complete a monthly pre-billing triple check to help catch costly errors upfront.
• If your SNF is not already fully electronic, incorporate key documents into your software system, e.g., physician certifications, therapy plans of care, etc.

2. Educate Aggressively

• Educate billing staff on the importance of checking the status of Medicare claims and monitoring for status code “SB6XXX,” which indicates a claim has been selected for pre-payment review and quick action is necessary.
• Communicate the importance of keeping facility information updated with CMS and your MAC so letters are getting into the hands of the correct officials.
• Owners, authorized officials, and administrators need to be updated within 30 days of any change utilizing the “change of information” option on Form 855A.

3. Response Assignment

• Designate a response team along with one individual to be responsible for leading the process. Proper management of the response team helps ensure nothing falls through the cracks.
• Notify contract rehab if applicable.
• Medical records should gather requisite information from all involved staff/departments. A few examples of what may be requested include:
• Dated notices of non-coverage
• UB-04 for dates of service billed
• Hospital discharge summary
• History and physical
• Minimum Data Set (MDS)
• Physician orders, certification for SNF care, and progress notes
• Medication administration records, treatment administration records, and therapy records

4. Response Review

• Assign a member of nursing management to review and organize the information for flow and content. Your packet should start with the date of admission and seamlessly flow through the end date of services being reviewed.
• Use cover sheets to separate sections and highlight to draw the eye to key areas of information.
• Make sure every piece of documentation requested is present and the entire response packet is meticulously organized.
• Include all information to support the MDS look-back period.

5. Submit & Follow Up

• The No. 1 method of submission—MAC portal. This eliminates the chance of your hard work getting lost in the mail and is the fastest way to get your beautifully organized packet into the reviewer’s hands.
• If you must send paper, be sure to keep a full copy of the entire packet and send it certified mail—no exceptions!
• Task your billing department with monitoring the status.
• Keep a tracking spreadsheet on a shared drive so key parties are aware of the claims being reviewed. Update the status monthly, at a minimum.

Five Quick Facts About TPE

• You have 45 days from the date of notification to respond.
• All claims on or after October 1, 2019 are eligible for review.
• CMS will attempt to exclude from review any claims with COVID-19 as the primary reason for skilled care.
• Pre-payment reviews mean that you will not be paid for the claim until it clears the review process.
• Professionals at FORVIS are here to help you! Please reach out with questions or if you need assistance with an evaluation of the documentation being submitted.

If you have already implemented all or some of these practices, that’s great! If not, please set aside time now to meet with key staff and get the ball rolling. The fact of the matter is TPE is here. Now is the time to prepare your staff to navigate this new program efficiently and effectively and reduce the risk of losing out on necessary reimbursement.

For additional information, please see our FORsights™ article, “WPS SNF Providers Five-Claim Probe & Educate Reviews.”

This article is for general information purposes only and is not to be considered as legal advice. This information was written by qualified, experienced professionals at FORVIS, but applying this information to your particular situation requires careful consideration of your specific facts and circumstances. Consult a professional at FORVIS or legal counsel before acting on any matter covered in this update.