The Centers for Medicare and Medicaid (CMS) has rolled out many initiatives since the Public Health Emergency ended in May of 2023.  One initiative in specific is the Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review. If you still have not seen or heard about it, and you operate a SNF, you will! The Transmittal 12037 outlines the specific probe audit. 

The purpose of the audit is to lower the SNF improper payment rate. The Comprehensive Error Rate Testing (CERT) program for SNFs projected an improper payment rate of 15.1% in 2022, up from 7.79% in 2021. 

The primary root cause of SNF errors was found to be “missing documentation”.

The key elements of the audit include that your Medicare Administrative Contractor (MAC) will select 5 claims from each selected provider. The MAC will only complete one (1) round of probe and educate for each selected provider, instead of the typical three (3) rounds. Typically, the audits are pre-pay audits, unless requested and approved to be otherwise.

When you receive the letter from your MAC, you will have to upload the medical record documentation to support the audit for Medicare Part A Patient Driven Payment Model (PDPM) reviews. If you do not have your Medicare Certification and Re-Certifications uploaded to your Electronic Medical Record (EMR), or are not using electronic forms, you will be scrambling to find these documents. If the rest of the records are submitted without critical information, you will fall into the statistic of “missing documentation” as a reason for errors.

LW Consulting, Inc. has prepared a SNF Claims Documentation Request List to assist your with making sure that you submit all of the required information. Follow the link and use the form for each record that you upload.

If you have any questions or want LWCI to provide a “test run” for you, reach out to Kay Hashagen, at [email protected] or (410) 777-5999. 

LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!