Skilled Nursing Facility 5-Claim Probe and Educate Review

Published 03/08/2024

The Comprehensive Error Rate Testing (CERT) program for SNFs (skilled nursing facility) projected an improper payment rate of 15.1 percent in 2022, up from 7.79 percent in 2021. SNF service errors were determined to be the top driver of the overall Medicare fee-for-Service improper payment rate. Part of the reason for the significant increase in the improper payment rate may be the change from the Resource Utilization Group (RUG) IV to the PDPM (patient driven payment model) for claims with dates of service on or after October 1, 2019. The primary root cause of SNF errors was found to be missing documentation.

The Centers for Medicare and Medicaid Services (CMS) is implementing a five-claim probe and educate medical review strategy that allows for maximum outreach to all SNFs and offers provider-specific education, as necessary, to prevent future improper payments. If Palmetto GBA identifies an improper payment we will adjust/deny the individual claim payment, as appropriate, and provide education.

  • Every skilled nursing facility (SNF) in our jurisdiction will have claims reviewed
  • Palmetto will select 5 claims from each selected provider 
  • Palmetto will complete one (1) round of probe and educate for each selected provider instead of the potential three (3) rounds as instructed by the traditional TPE program
  • Education offered will be individualized based on the claim review errors identified in the probe

CMS has issued provider education content related to this national review program in MLN Matters: MM13164 (PDF)

Key points to remember:

  • SNF 5-Claim Probe and Educate (SPE) reviews will not be concurrent with Targeted Probe and Educate (TPE), but a provider may progress from SPE to TPE
  • If you are submitting claims for review under TPE, you will continue on TPE until the TPE process is completed
    • Successful performance claim/charge denial rate <20 percent — Removed from TPE
    • Unsuccessful performance claim/charge denial rate >20 percent — Progressed to next round of TPE (referral to CMS after 3 unsuccessful rounds for further actions)
  • Unsatisfactory performance for SNF Probe and Educate (SPE), may lead to provider being placed on TPE for dates of service at least 45 days after SPE has been completed

Review selection by Palmetto GBA (your MAC) for TPE or SPE does not exclude you from review by other CMS contractors. Your claim may still be selected for review by the CERT contractor or other CMS entities.

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