In June 2023, CMS announced that all skilled nursing facility (SNF) providers nationwide would undergo a 5-claim pre-payment Targeted Probe and Educate (TPE) review by their Medicare Administrative Contractor (MAC). This decision was due to a significant increase in improper payments from 2021 to 2022, as determined by the Comprehensive Error Rate Testing (CERT) program. The change from Resource Utilization Group (RUG) IV to the Patient-Driven Payment Model (PDPM) on October 1, 2019 also influenced the timing. The SNF 5-claim Probe and Educate program aims to assist SNFs in understanding how to bill appropriately under this new payment model and decrease improper payments.
According to CMS, providers with higher error rates from the initial TPE or unusual billing and utilization patterns are now receiving a notice asking for a pre-payment review of 20 to 40 claims. The sample size is intended to allow the MACs to review enough claims to be representative of provider behavior. This claim size also allows MACs to assess whether claims generally have the necessary supporting documentation to meet Medicare rules and requirements, while not being overly burdensome. CMS has encouraged MACs to use all available data sources when selecting providers to include in the TPE process.
After each round of 20 to 40 reviews, providers will receive a letter detailing the review results and offering a one-on-one education session. MACs will also provide education throughout the TPE review process, when errors that can be easily resolved are identified, helping the provider avoid additional similar errors later in the process. During the education session (usually held via teleconference or webinar), the MAC will educate the provider regarding claims with errors representative of those identified during review. Providers may ask questions regarding their claims and the CMS policies that apply to the claim that was reviewed. The education session after each round is developed based on the review findings from the most recently completed round of reviews and is not the same as that given to other providers unless errors found in the reviewed claims are the same. Education will reinforce corrections that should be made for errors that continue to be identified.
TPE Review Results – Next Steps for SNFs
It is recommended that SNF providers review the results from their 5-claim TPE and make sure processes are in place to have supporting documentation of care and services provided. Some common issues noted with the initial 5-claim reviews were physician certifications and re-certifications being incomplete or untimely, providers not having or submitting physician signature logs with names of practitioners, inadequate documentation submitted to support care and services, and missing documentation.
This may be a good time to reach out to a professional to help gauge whether your processes developed following the initial TPE reviews are working to provide adequate support of claims. If you have any questions or need assistance, please reach out to a Senior Living & Long-Term Care professional at Forvis Mazars.