CMS Initiates National SNF 5-Claim Probe and Educate Review

CMS has reissued transmittal instructions for Medicare Administrative Contractors (MACs) to perform a 5-claim probe and educate medical review on every skilled nursing facility (SNF) in their jurisdiction. The purpose of this widespread review, which will be implemented in waves over the next year beginning June 5, 2023, is to lower the SNF improper payment rate. Providers should be on the lookout starting in early June for medical records requests related to this program.  

The key elements of this project include:  

• All MACs that review SNF Medicare claims. 
• MACs will select five (5) claims from each selected provider unless they are already under review or a very low volume provider. 
• MACs will complete one (1) round of probe and educate for each selected provider instead of the potential three (3) rounds as instructed by the traditional targeted probe and educate (TPE) program. 
• Education offered will be individualized based on the claim review errors identified in the probe.

This will be a pre-pay review unless a provider requests a post-pay review for hardship. If the MAC identifies an improper payment, it will adjust the individual claim payment, as appropriate, in addition to providing education – including the explanation for denial or payment adjustment. MACs may prioritize providers with errors in all five claims reviewed for the traditional and more extensive TPE program.

CMS will issue provider education content related to this national review program through the MLN Connects® newsletter.