Medicare Administrative Contractors begin 5-claim targeted probe and educate reviews 6/5/23

How do YOU rate? Are YOU ready for scrutiny?
Medicare Administrative Contractors (MACs) kickoff widespread 5-claim targeted probe and educate medical reviews or TPEs, beginning June 5th.

The Centers for Medicare and Medicaid Services (CMS) issued guidance (Change Request 13164) regarding the review, intended to lower the skilled nursing facility (SNF) improper payment rate. The Comprehensive Error Rate Testing (CERT) program for SNFs projected an improper payment rate of 15.1% 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 MAC data analysis; MACs will select 5 claims for prepayment review (with occasional post-pay, if requested by the provider due to financial burden).

Following review, a detailed results letter will be sent indicating next steps. For providers with an error rate at or below 20%, MACs will provide widespread education with the option for the provider to request 1:1 education.

For providers with an error rate above 20%, MACs will schedule 1:1 education.

Consider an independent review to determine:

—          Compliance with all applicable federal regulations and guidelines

—          SNF PPS MDS coding and billing accuracy

—          Process improvement and educational opportunities

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