The Centers for Medicare & Medicaid Services (CMS) took aim at improper skilled nursing payment rates in its latest memo on May 4.
This appears to be a reaction from data compiled using the Comprehensive Error Rate Testing (CERT) program, which projected an improper payment rate of 15.1% in 2022 for Medicare Fee-for-Service (FFS), nearly double compared to 7.79% in 2021.
“They felt the error rate was so high that they needed to check everyone,” Alicia Cantinieri, vice president of MDS policy and education for Zimmet Healthcare Services Group told Skilled Nursing News.
Zimmet, in partnership with Simple, plans to host a webinar outlining the CMS memo on Monday, May 15.
SNF service errors were the top driver of overall Medicare FFS improper payment rates, CMS said.
Medicare administrative contractors (MACs), effective June 5, will perform a “5 claim probe and educate medical review” for operators in their jurisdiction, CMS said in the memo.
In other words, MACs will select five claims from each selected provider and complete one round of probe, educating for each selected provider; MACs would usually provide education after the third probe, CMS officials said in the memo.
Cantinieri said CMS will start with the top 20% that they feel are the highest risk for errors based on data collection, and will continue to a rolling audit for all facilities that participate in Medicare FFS.
“With only five claims, having an error on one puts you in the less than 20% [bracket]. But with errors on more than one claim, you may end up with one-on-one education versus group regional education,” said Cantinieri. “Five out of five errors is going to definitely get the facility one-on-one education with the MAC.”
It’s unclear if CMS will adjust or deny payments if a facility has errors on one or more claims, she said. And, it remains to be seen if CMS will put out further clarification on the matter, or if this is a test of sorts for future probes related to improper payment rates.
“I can see CMS expanding it, possibly. They already do look at a lot of claims, but if they find that every facility has at least one or two claims out of five with errors, that tells them a lot,” said Cantinieri.
CMS’s probe is an attempt to correct billing practices under PDPM for all SNF providers that bill Medicare. This new strategy calls for “maximum outreach” to all SNFs while also offering provider-specific education to prevent future improper payments.
The change request doesn’t include any legislative or regulatory policies, according to the memo.
“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 (Patient Driven Payment Model) for claims with dates of service on or after Oct. 1, 2019,” CMS officials said in the memo. “The primary root cause of SNF errors was found to be missing documentation.”
Education will be individualized based on claim review errors identified by the probe.
CMS doesn’t intend for this additional work to translate to additional costs, according to the memo. If the additional probe into payment rates falls outside of a MAC’s current scope of work, they need to withhold taking action until more direction is obtained from the contracting officer, CMS said.
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