MACs kicked off widespread 5-claim reviews last month – SNFs are at risk for adjusted or denied claims.

The Centers for Medicare and Medicaid Services (CMS) announced targeted probe and educate reviews (TPEs), intended to lower the skilled nursing facility (SNF) improper payment rate. The Comprehensive Error Rate Testing (CERT) program projected a significant increase in improper payment rate for SNFs in 2022. Missing documentation was found to be the primary root cause of SNF errors.

All SNFs that submit claims for Medicare SNF services will be subject to review.

Beginning with the top 20% of providers that show highest risk based on Medicare Administrative Contractors (MAC) data analysis; MACs will select 5 claims for prepayment review, with occasional post-pay review if requested by the provider due to financial burden.

If your facility is selected for a 5-claim review soon, your facility is likely in the MACs top 20% of providers that show highest risk. Celtic recommends assessing for patterns and trends in your facility’s claims history, to determine why your facility triggers at the 20th percentile.

MACs will review claims, and based on their findings, provide widespread or 1:1 education. If the MAC identifies improper payment, they will adjust or deny the claim, and provide education on the issue.

Are YOU ready for scrutiny? Prepare for your review with Celtic to avoid denied claims. We’ll help you to determine:

  • Conformance with all applicable federal regulations and guidelines
  • Accuracy of SNF PPS MDS coding and billing
  • Opportunities for process improvement and education

Celtic frequently provides targeted and comprehensive Medicare compliance audits and provides customized education to design and/or strengthen existing facility processes. Our team of subject matter experts have a proven track record of winning or overturning denied claims.

Contact us today, let’s discuss how we can help you prepare for your MAC 5-claim probe.

About Lauren Videtto