Starting June 5, 2023, Wisconsin Physician Services (WPS) began contacting skilled nursing facility (SNF) providers of the upcoming Probe and Educate reviews. CMS directed all Medicare Administrative Contractors (MACs) to conduct pre-payment reviews of five Medicare Part A claims for all SNF providers with few exceptions. Those exceptions are for those providers already under medical review from any CMS contractor and low-volume providers defined as less than five Medicare Part A claims per calendar year.
The reviews are being conducted due to a sharp increase in improper payments from 2021 to 2022. In 2021, there was a 7.79% error rate with a projected rate of 15.5% in 2022. For the 2022 claims, the most prevalent reason for errors was missing or insufficient documentation. Depending on results from the five-claim pre-payment review, providers can expect the following from WPS:
- Error rate of less than 20% (one of five claims in error)
- Widespread education
- Option for 1:1 education if requested
- Error rate of greater than 20% (two to four claims in error)
- 1:1 education – WPS will contact provider to schedule the education if two or more claims are in error
- Education to include claim-specific information
- Discussion may be monitored by CMS
- Five of five claims in error
- 1:1 education
- Prioritized for Targeted Probe and Education (TPE) where 20 to 40 claims will be requested and can span from one to three rounds
- Failure of all three rounds – CMS will determine if the provider should be targeted for fraud, waste, and abuse
Some things to keep in mind regarding the Probe and Educate review process:
- Providers have 45 days to submit documentation once requested. Failure to submit documentation is an automatic denial of the claim without appeal rights except in cases of a natural disaster.
- Any claims that took place on or after October 1, 2019 are eligible for review. Claims with a diagnosis of COVID-19 will attempt to be excluded from those chosen when possible. Any flexibilities related to the public health emergency (PHE) from March 1, 2020 through May 11, 2023 will be applied as indicated.
It is recommended that all SNF providers make sure their contact information is updated in the WPS portal to allow for streamlining communication. The initial contact from WPS will be a phone call to the provider to establish a point of contact. The provider will then receive a letter either through the WPS portal, mail, or email. Providers should follow the additional documentation request instructions on the WPS website when submitting required documentation. The documentation can be submitted through the WPS portal, mail, or delivery service. It can be hard copy, DVD, CD, or encrypted flash drives.
If you have any questions or need assistance with an evaluation of medical record documentation being submitted, please reach out to a professional at FORVIS or use the Contact Us form below.