What Skilled Nursing Facilities Need to Know to Prepare for the CMS 5-Claim Probe

June 22, 2023
June 28, 2023
Polaris Group
June 28, 2023

The Centers for Medicare and Medicaid Services has instructed MACs to perform a 5-claim probe on each SNF in their area.

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Beginning June 2023, The Centers for Medicare and Medicaid Services has instructed Medicare Administrative Contractors (MACs) to perform a 5-claim probe on each SNF (Skilled Nursing Facility) in their area. Here is what you need to know.

What is the 5-claim probe?

The 5-Claim Probe is a CMS auditing program designed to identify potential billing errors to reduce improper payments.

Why is CMS doing this?

The Comprehensive Error Rate Testing (CERT) projected the improper payment rate would double between 2021 and 2022 from 7.8% to 15.1%. The primary reason for improper payments were SNF service errors, mostly in missing documentation. A goal of the 5-claim probe is to help improve billing practice comprehension by SNF providers.

How the 5-claim probe works

Step 1: MACs select 5 claims for pre-payment review (with occasional post-pay review if requested by the SNF). Claims will be selected first from the top 20% of facilities that have the highest risk based on MAC data analysis. The review will assess medical record accuracy, service appropriateness, and documentation.

Step 2: After 5 claims are reviewed, MACs send letters documenting results. Results will include claim-by-claim denial rationales and contact information to set-up facility education.

  • For providers with an error rate <20%, MACs will provide the option for a 1:1 educational telephone call to discuss the findings.
  • For providers with an error rate >20% (2 or more errors), MACs will provide 1:1 education through a telephone call
  • For providers with a 100% error rate (5/5 claims), the facility will participate in a 3-round targeted probe and educate (TPE) review.

Step 3: The 1:1 education session with MACs will give facilities information on claim specific information and denial reasons. Facilities will have the chance to ask questions and receive feedback.


Why the 5-claim probe matters

The 5-claim probe has significant implications for SNFs. The audits conducted under this program can result in several outcomes, including the identification of overpayments or underpayments. If billing errors are identified, SNFs may be required to repay any overpayments and adjust their billing practices accordingly.

Moreover, the 5-claim chart review can have long-term consequences. If substantial issues are discovered, the facility will need to participate in a TPE which involves an extensive review of billing practices.

Polaris Group can help

Given the potential impact of the 5-claim probe, SNFs need to take these audits seriously and proactively address deficiencies.

Polaris Edge, our compliance consulting program, can help. Polaris Edge is a suite of year-long, customizable compliance program consulting services designed to enhance nursing home compliance 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. Polaris Edge services include a 4-Day MCOA or 2-Day PDPM audit, onsite or remote facility training, and monthly claim audits.

Facilities need not fear the 5-claim probe if they are prepared.

With proper documentation and coding, training, and internal audits, SNFs can proactively address deficiencies, reduce billing errors, and continue to deliver high-quality care to residents.

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