CMS Targeted Probe: Top 10 Things for Providers to Know

Since the initiation of PDPM in October of 2019 providers have been long awaiting medical review from CMS program integrity to assess the accuracy of interdisciplinary team documentation.

Now they are here and even though the 45-day turnaround is a quick one, no need to fret. We are here to provide you with key areas to know for success.

  1. When did CMS announce the new Targeted Probe? The initial change request (CR) was published May 4th, 2023- Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review
  2. How many claims will be requested from my community? 5- claims for prepayment review (with occasional post-pay, if requested by the provider due to financial burden) from the universe of claims for all SNFs that submit claims for Medicare SNF services within the contractor’s jurisdiction.
  3. And who is requesting these? Your Medicare Administrative Contractor (MAC). That’s right! Time to open those letters sitting on your desk received last week from your MAC.
  4. That sounds like A LOT for my MAC to handle.. Is there a specific strategy used by the MAC regarding when notices are sent? The contractors are directed to implement the SNF 5-claim reviews on a rolling basis beginning with the top 20% of providers that show highest risk based on MAC data analysis.
  5. What is the reason for these reviews? The stated purpose is to have the MACs perform a 5-claim probe and educate medical review on every SNF in their jurisdiction. The purpose of the widespread review is to lower the SNF improper payment rate.
  6. What impact does CMS hope reviews will have? The aim is to increase comprehension of correct billing practices under the PDPM by all SNF providers that bill Medicare.
  7. What is meant by the “E” Educate in TPE? Education is offered post-review from your MAC and is individualized based on the claim review errors identified in the probe. Take full advantage of these opportunities to engage with reviewers and learn from them!
  8. So, is this the same as prior traditional TPE from CMS? MACs 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.
  9. When did this start? EFFECTIVE DATE: June 5, 2023
  10. And explain to me again.. Why is CMS going to be reviewing claims? 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% in 2021. Furthermore, 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.
  11. (I know.. 10 just wasn’t enough). Great, now that I understand “Why”, what can my team prepare for based on prior noted errors? The primary root cause of SNF errors was found to be missing documentation.

Also, take time to review prior TPE industry trends which includes: the signature of the certifying physician not included; documentation does not meet medical necessity; encounter noted do not support all elements of eligibility, and missing or incomplete initial certification or recertification.

Review time is here. No turning back.

Want to learn more about how Broad River supports medical review success? Reach out to us here.