The Centers for Medicare & Medicaid Services (CMS) launched the SNF 5-Claim Probe and Educate (SPE) in 2023 in response to a 15.1% improper payment rate under the Patient-Driven Payment Model (PDPM), identified in 2022 (2023). The probe was meant to audit five PDPM claims per skilled nursing facility (SNF) and offer education based on the findings. At the time of the roll out, CMS projected that 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.
Although it is not posted on the CMS website, Medicare Administrative Contractors (MAC) have announced that CMS has closed that probe effective June 30, 2025. One might think this is good news and breathe a sigh of relief, but beware! Although the SPE has closed, if a facility had an error rate between 60% and 100% on that probe, it should be on “high alert” watching for notices from the MAC.
The word is that CMS has mandated that any provider that had 100% error rate on the SPE is going to be moved to a Targeted Probe and Educate (TPE) audit. It is also believed that providers with a 60% to 80% error rate will also be prioritized for a TPE audit.
What were the most common errors identified in the SPE?
- No documentation was submitted for review
- Documentation didn’t support the HIPPS code billed
- No Physicians Certification or Recertification was present
- The documentation submitted was insufficient to support the services that were billed
What should you do if your SPE error rate was greater than 60%?
- First and foremost, you should know what your error rate was on the SPE audits. If you don’t know, you should contact your MAC.
- Next, you should be on the lookout for communication that you have been selected for a TPE audit review. This information will come via letter or online from the auditor who has been assigned to review your TPE documents.
- You will be notified with an Additional Document Request (ADR) letter, one for each claim that has been chosen. For Round 1 of a TPE, the auditor will review between 20-40 claims. They can be either Pre-Pay or Post-Pay. At LW Consulting, Inc.(LWCI), we have seen that most are Pre-pay. Be aware of any claims that are listed as “on hold” for payment, as this might be an indicator of claims to be reviewed.
- Submit documents within 45 days after notice of the ADR. Review the documents before submitting them to ensure that all required physician documentation is signed and dated. Obtain Delayed Certifications and/or attestations for any missed signatures.
- Be aware that the TPE procedure includes up to three rounds of audits. If on Round 1 you have more than a 20% error rate, you will receive one-on-one training with the auditor, then have 45 days to improve, and then you will get another 20-40 claims reviewed. The same scenario will occur for Round 2 and Round 3. If you do not pass Round 3, the MAC will refer you to CMS. You do not want to be referred to CMS as that next set of audits might be extrapolated back up to six years.
Best Practice Actions
- If your SPE error rate was above 60%, be on the ready for a TPE audit follow-up.
- Make sure you know the focus issues identified by your SPE audits.
- Review your training and systems to ensure that common errors are not continuing to occur.
- Implement internal and/or external audits to monitor readiness for a Round 1 TPE.
LWCI is ready to assist with training, systems review, and the audit process to help your organization prepare for an impending TPE Round 1 audit. Please contact Kay Hashagen, PT, MBA, RAC-CT, Senior Consultant at khashagen@lw-consult.com or (410) 777-5999 to discuss a plan.
| Sources: |
| Skilled Nursing Facility Probe and Educate Review. CMS.gov. (2023, March 15). https://www.cms.gov/files/document/mm13164-skilled-nursing-facility-probe-and-educate-review.pdf |
