Is Your SNF Involved in the “SPE” Yet?

As you should be aware, the Centers for Medicare and Medicaid put out a statement in Transmittal 12037 regarding the intention to have the Medicare Administrative Contractors (MACs) perform a five (5) claim probe and educate medical review on every Skilled Nursing Facility (SNF) in their jurisdiction. The purpose of this widespread review is to lower the SNF improper payment rate. This transmittal was published May 15, 2023. The reason for the audit was because of an increase in errors that was primarily due to missing documentation.

The project is called “SNF 5-Claim Probe and Educate,” so the term “SPE” has been used to differentiate it from other Targeted Probe and Educate (TPE) reviews. It is important to remember that the initial purpose of any TPE is to identify root causes of errors, educate and then re-assess. The typical TPE is a series of three reviews; the entity will have three chances to submit documentation, have education and then a review before next steps are implemented [if there is not improvement]. However, the SPE is different in that there is only one review. Each SNF will get a request in the form of an Additional Document Request (ADR) for 5 PDPM claim records for the SPE review. These are PRE-PAYMENT reviews.

The SPE excludes SNFs currently under a Supplemental Medical Review Contractor (SMRC) audit and TPE, as well as claims containing the COVID-19 diagnosis during the Public Health Emergency (PHE).

In a recent AAPACN MDS General Discussion Community Digest blog, one person commented that they “received 5 residents for ADR and most of the claims are November claims. Is it normal that they send an ADR for residents that are still in our facility and with recent claims?” The answer is YES, and that is because CMS prefers to do pre-payment reviews for these 5 record SPEs. The response indicated that …” the SNF has to let the MAC know if it would be a financial hardship to have the records reviewed pre-pay”. If you do not reach out with a request to your MAC, SPE audits will be pre-pay, on current Medicare A residents.

One client, who has a lot of SNFs, currently has over 400 requests for SPE, and that pre-pay out-of- pocket amount is in the Millions! If you have not received any ADR requests from your MAC for the SPE yet, now is the time to prepare! You will get them between now and the end of May 2024, when the year is up.

If you need assistance with how to respond to the ADR, understand your risk, or want a pre-SPE assessment, LWCI consultants will be happy to assist. Contact Kay Hashagen at (410) 207-8338 or [email protected].