CMS has directed Medicare Administrative Contractors (MACs) to audit 5 Medicare claim submissions from every SNF as part of a widespread review to lower the SNF improper payment rate (likely due to unintentional increases brought forth by PDPM). This will be implemented in waves over the next year beginning June 5, 2023, so be on the lookout for these record requests.

The key elements of this project include:

• All MACs that review SNF Medicare claims
• MACs will select 5 claims from each selected provider
• 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.
• Education offered will be individualized based on the claim review errors identified in the probe

If the MAC identifies an improper payment, they will adjust the individual claim payment, as appropriate, in addition to providing education, including their explanation for denial or adjustment of payment.

As a result of the audit:

Providers with 1/5 claims error rate will have to the option to receive 1:1 education

Providers with an error rate of 2/5 claims or more will need to schedule 1:1 education

Providers with a 5/5 claims error rate will be prioritized for the Targeted Probe and Educate (TPE) program.

Some proactive notes to consider:

• Educate front office and/or business office team members to be on the lookout for these requests from CMS as to not confuse them with junk mail/e-mail and share with the appropriate individual(s) at the organization as soon as possible.
• Assess the need for a proactive review/audit of Medicare claims submissions and supporting documentation to identify any potential errors in advance and submit for correction if found.
• Incorporate this activity in your Corporate Compliance efforts- Include this as a topic in a Committee meeting, note as an auditing effort, report findings to Committee and rise to the Board if warranted
• Contact your financial advisor/partner to further prepare for the MAC audit

Please reach out to your M3 Account Executive or Risk Manager for further information.

M3 Insurance | Senior Living and Social Services Practice Group