Nursing Home Medicare Program Integrity Initiative Underway

The Centers for Medicare and Medicaid Services (CMS) has kicked off its Medicare claim review initiative and recently provided some additional details about the process. As part of the effort to lower the Skilled Nursing Facility (SNF) improper payment rate, National Government Services (the Medicare Administrative Contractor (MAC) serving New York State) will be reviewing five claims from every Medicare-billing SNF in the state. If errors are found, the SNF will be offered education, helping them to avoid future claim denials and adjustments.

Similar to the current Targeted Probe and Educate (TPE) medical review strategy, the SNF 5-Claim Probe and Educate Program will include one-on-one provider education at the completion of a small sample of claim reviews. Review results letters will detail the denial rationales for each denied claim. The MAC will provide education including claim-specific information, such as clinical facts and corresponding denial reasons. This education will allow providers to review the claim decisions and ask questions. Note that unlike the one to three rounds of review a provider receives through TPE, under this initiative, each SNF will undergo only one round of review.

The SNF 5-Claim reviews began on June 5, 2023 and reach back to claims for services furnished after Oct. 1, 2019. Claims containing the COVID-19 diagnosis will be excluded from the review.

More information on the initiative is available here and in a Medicare Learning Network (MLN) article posted here.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841