Audits have been trickling in for the 5-claim improper payment probe and educate review led by the Centers for Medicare & Medicaid Services (CMS), which had announced its plans to implement the review for all SNF operators in the country in June.
A webinar hosted by Therapy Management Corporation (TMC) on Tuesday delved into how operators can navigate the upcoming audits.
Five claims related to the Patient-Driven Payment Model (PDPM) from each SNF will be audited in one round to determine if the claims are accurate, or if there are errors on what was submitted, said Christina Bruenderman, director of denials and appeals for TMC.
CMS has started with the top 20% of providers that show the highest risk, Bruenderman said, based on the Medicare administrative contractor (MAC) data analysis. Requested documentation will need to be returned within 45 days of an additional documentation request (ADR) notice, she said, and the claim may be denied if documentation isn’t returned or is untimely.
MACs have a month to complete the review and process the claim once they get all documentation.
The federal agency decided to launch the probe after finding that there was improper payment on 15.1% of claims following a 2022 comprehensive error rate testing (CERT) program. The payment error rate nearly doubled from 7.79% in 2021. Inadequate documentation, insufficient or missing documentation required in Section GG of the Minimum Data Set (MDS) assessment were the main reasons behind improper payments, CMS said.
“This was huge news for our industry because CMS does not typically apply one audit to every single facility in the country,” added Bruenderman. “This five claim probe that CMS announced really is the first CMS audit to strictly focus on PDPM and to be applied to all sites.”
Exemptions for the 5-claim probe
While the probe is still in its early stages, Bruenderman said the audits will be similar to a Targeted Probe and Educate (TPE) audit, but only focusing on PDPM. In fact, if an operator is already receiving TPE audits tied to PDPM claims, they’re exempt from the 5-claim probe, she noted.
Providers involved in supplemental Medicare contractor reviews, known as SMRCs, are also exempt from the 5-claim probe – such reviews were unveiled around the same time as the 5-claim announcement in May.
The third exemption, Bruenderman said, involves claims that contain a Covid diagnosis obtained during the public health emergency “when possible.”
5-claim probes will be pre-pay audits, unless there’s financial burden
CMS also prefers that providers follow a prepayment review process, meaning reimbursement timeliness is based on completing the audit. But, the agency said a post-payment audit is an option if an operator can prove there’s a financial burden.
So far, Bruenderman said clients have seen a TPE or 5-claim audit triggered when they try to submit billing for reimbursement. CMS has come back and said that its reviewing the claim as part of such an audit, and there was no mention of switching to a post-payment audit.
“My understanding is that since they were offering that option, if that was something you were interested in, that you would need to request that from the CMS auditor,” said Bruenderman.
Of TMC’s clients that have received a 5-claim probe letter, none have seen a resolution from CMS yet, she said.
“The next big question is what to expect after the claims are reviewed,” said Bruenderman. “We have facilities that are waiting on decisions from CMS.”
Resolutions will depend on the amount of errors, according to the initial CMS announcement. Providers with 20% or less errors, meaning one claim error out of the five, can request one-on-one education.
Those with a more than 20% error rate, or two or more errors out of the five, will be contacted by the MAC for one-on-one education as a requirement.
What’s more, a claim with an error may be adjusted or denied altogether if improper payment is identified, she said. But, providers still have appeal rights just like they do for any other TPE audit.
“The goal is, when you get the ADR notice for these probes, to get the documentation turned in and have as few errors as possible, so that you don’t get to that point of having the TPE audit,” said Bruenderman.
As for how many attendees of TMC’s webinar have received notices from the federal agency, a majority – about 80% of providers – have yet to see the letters, according to an informal poll conducted during the webinar.
