The Centers for Medicare and Medicaid Services has instructed MACs to perform a 5-claim probe on each SNF in their area.
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 and reduce improper payments. Medicare Administrative Contractors (MACs) will be reviewing a small number of claims from every Medicare-billing SNF in the country.
Why is CMS doing this?
CMS' Comprehensive Error Rate Testing (CERT) program recently projected that the improper payment rate would double between 2022 and 2023 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
MACs will be auditing every Medicare-billing SNF in the country. If the audit reveals a facility was overpaid due to billing errors, SNFs may be required to repay any overpayments and adjust their billing practices accordingly.
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.
