CMS has released an update to the original transmittal 12015 as current Transmittal 12037, effective June 5, 2023. CMS has directed all Medicare Administrative Contractors (MACs) to perform a probe and educate review in a format similar to the traditional targeted probe and educate (TPE) review. This current transmittal clarified the original transmittal to include language that improper payments identified during this new review would be adjusted or denied in addition to offering education to the provider.
CMS has instructed the MACs to review five pre-payment claims from each provider in their jurisdiction due to an improper payment rate that nearly doubled from 7.75% in 2021 to 15.1% in 2022. CMS’ stated goal is to lower the skilled nursing facility (SNF) improper payment rate and prevent future improper payments through widespread review.
All MACs will be responsible to complete only one round of probe and educate for five claims from each provider in their jurisdiction. Following the review, individualized education will be offered to the provider based on identified errors. Further instructions from CMS to the MACs include:
- Providers may request post-payment review due to financial burden
- Initiate the five-claim review with the top 20% of providers demonstrating the highest risk factors as determined by the MAC
- A letter with the detailed results of claim-by-claim denial rationales will be sent to the provider once the review is complete and also will report the results to CMS
- The detailed results letter also will be sent to providers with no findings of error
- If 20% or less of the claims are in error, the MAC will provide widespread education and also offer the provider 1:1 education if desired with a point of contact for education request included in the letter
- MACs will reach out to providers to schedule 1:1 education if two or more claims are in error (greater than 20%)
- The 1:1 education will include clinical facts and denial reasons. Providers will be allowed to review the denial decisions, ask questions, and receive feedback to improve compliance
- Education sessions may be monitored by CMS in listen-only mode
- Waivers in place during the public health emergency shall be considered and claims with a COVID-19 diagnosis will be excluded when possible
- Following the review of the first 20% of providers, a list of top 10 errors and the rate of occurrence will be compiled
- Providers with all five claims in error will be prioritized for TPE review if that SNF is currently included in the existing medical review strategy
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