Even though the Centers for Medicare & Medicaid Services (CMS) officially ended its 5-Claim Probe process for nursing homes as of June, many providers still find themselves in limbo with audits.

While no new claim requests will be issued – the Skilled Nursing Facility (SNF) 5-Claim Probe process ended on June 30 – some facilities might have been in mid-process awaiting word on the status of their audits from their Medicare Administrative Contractors (MACs).

According to Christina Bruenderman, director of denials and appeals at TMC, providers first received word of the phase-out earlier in June. Updates came from certain MACs, such as the Wisconsin Physicians Service (WPS), which is contracted by CMS to process Medicare claims, conduct audits, and provide provider education in designated regions.

Bruenderman spoke about the changes to the 5-Claim Probe process and what lies ahead during a webinar held on Wednesday.

CMS’ decision to end the 5-Claim Probe process was made because overall error rates were improving, Bruenderman said. However, this announcement came as some providers were still in the middle of some facilities’ 5-claim reviews. In such cases, no further records were requested. Instead, CMS instructed MACs to base final error rates only on claims already reviewed.

“So for example, if two claims were audited and one claim was paid and one was found to have errors, then your error rate for the 5-Claim Probe would be 50%,” she said.

Importantly, those who had submitted claims prior to June 30 would still receive results from their MACs, she said. 

“Some of you may have already had all five of your claims audited, and you’re just waiting on decisions. So don’t panic. If you’ve submitted something, your records will still be reviewed and you will receive a decision,” she noted.

CMS launched the 5-Claim Probe in 2023 in response to a 15.1% improper payment rate under the Patient-Driven Payment Model (PDPM), identified in 2022. The probe was meant to audit five PDPM claims per SNF and offer education based on the findings. Providers with error rates under 20% could request optional education, while those with 20% or more were required to complete a one-on-one session. Facilities with 100% denial rates faced more intensive Targeted Probe and Educate (TPE) audits.

Timeline for pending audits

It typically takes around 60 days for MACs to issue a decision for these 5-Claim Probes, and if a facility hasn’t received results in that period, Bruenderman advised following up with the MAC auditor directly to avoid missing time-sensitive updates.

Though the 5-Claim Probe is now closed, if a facility has an error rate between 60% and 100%, it should be on “high alert” watching for notices from the MAC.

“CMS has mandated that any provider that had 100% error rate on the SNF 5-claim Probe is going to be moved to a targeted probe and educate or what we call a TPE audit. They also stated that providers with a 60% to 80% error rate will then be prioritized for a TPE audit,” she said.

Some providers have already begun receiving TPE audit notifications, Bruenderman said.

“Just last week, we received a couple, but they were for people that had a 60% error rate. So these are already starting,” she noted.

TPE audits are more thorough and educational in nature, designed to help facilities improve their claim practices over time.

If a facility is selected for TPE, it will receive a notification letter explaining the reason behind the audit. Unlike the 5-Claim Probe, TPE audits involve 20 to 40 claims per round and can span up to three rounds if a facility’s error rate remains high, Bruenderman said.

To succeed in TPE audits, Bruenderman suggested that providers closely monitor both their mail and electronic systems for communications from MACs. Timely submission of records is critical, she said, and submitting documentation early allows MACs to request any missing information before deadlines expire.

Common mistakes and preventing future denials

It’s important to understand why claims were denied, as lessons from the 5-Claim Probe can help providers improve documentation, meet deadlines, and avoid future denials – even after the process has ended.

Auditors denied claims when documentation failed to support the Health Insurance Prospective Payment System, or HIPPS, code under PDPM, often finding mismatches between the patient’s clinical record and the MDS – particularly in Sections GG, I, and O, for example, Bruenderman said.

Moreover, auditors issued denials when providers submitted incomplete or late certification and recertification forms. Missing signatures, unchecked boxes, or entirely absent forms triggered rejections too. CMS urged facilities to fix deficiencies by obtaining physician attestations, she said.

Another source of denials was when providers failed to include key records, such as therapy documentation or physician notes. In some cases, auditors claimed providers didn’t submit any documentation at all – often due to late submissions. CMS advised providers to still submit the missing records and request a reopening, Bruenderman said.

And so, facilities that had errors in the 5-Claim Probe should now place particular focus on those areas when preparing for TPE audits.

Providers should ensure that all records requiring physician signatures are signed and dated on time. Another best practice is to audit claims internally to ensure that documentation supports what was entered into the Minimum Data Set (MDS).

As for appeals, providers who received denials during the Five-Claim Probe can still do so. Even if the claim was denied and later overturned on appeal, CMS currently counts the original denial toward a facility’s error rate, Bruenderman noted.

Providers unsure of their error rates can contact their MAC for clarification, especially if there have been staffing changes or missing communications, Bruenderman.