Regulatory Update

Five Things to Know about the CMS Five Claims Probe

Polaris Group Profile
Polaris Group
June 28, 2023
July 18, 2023
Polaris Group Profile
Polaris Group
July 18, 2023

Learn how CMS's 5 Claim Probe & Educate Review program aims to help SNFs improve billing under the PDPM model.

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  1. This probe is designed to help your facility. In response to a projected doubled improper payment rate, CMS announced the 5 Claim Probe & Educate Review program. According to CMS, one reason for the increased rate may have been that SNFs misunderstood how to appropriately bill when the payment model changed from Resource Utilization Group (RUG) IV to the PDPM (patient driven payment model). The hope is this program will help SNFs understand how to bill more appropriately under PDPM.
  2. There may be long-term consequences for a poor review. Substantial errors identified in this review will require your facility to participate in a 3-round TPE (targeted probe and educate) review. This TPE will involve an extensive review of billing practices which can be financially costly, but also cost time and attention for your team to focus on the review.  
  3. MACs will focus on documentation, coding, and billing. Medicare Administrative Contractors will randomly select 5 claims for prepayment review from all claims the SNF submits. This selection will be on a rolling basis starting with the top 20% of SNFs that have the highest risk for errors based on MAC data analysis. The review will assess medical record accuracy, service appropriateness, and documentation.
  4. The MAC education session is an opportunity to receive feedback. The 1:1 education session with MACs will give facilities information on claim specific information and denial reasons. MACs will cover claim-specific information such as clinical factors and denial reasons. Importantly, facilities will have the chance to ask questions and receive feedback. The goal is to receive meaningful feedback such that SNFs can address problems and improve billing and documentation compliance.
  5. You can prepare. Given the potential impact of the 5-claim probe, SNFs need to take these audits seriously and proactively address deficiencies. Your facility can prepare and Polaris Edge can help. Polaris Edge is a suite of customizable compliance program consulting services designed to enhance nursing home compliance, documentation, and financial oversight. Polaris Edge will ensure compliance with PDPM MDS rules, identify and mitigate Medicare compliance risk for post-payment reviews and identify opportunities to obtain accurate revenue.

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