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The verification of requests will affect all nursing homes starting from 5 June

Every skilled nursing facility in the United States will be subject to a five-complaint scrutiny starting the week of June 5 as regulators look to better evaluate and root out improper payments.

The Centers for Medicare & Medicaid Services announced audits by Medicare administrative contractors in early May, later removing a related memo from public view. But several experts said the reviews will still take place on an ongoing basis, with MAC in each region required to withdraw five Medicare Part A applications from each facility they cover and review them for potential errors.

The results will lead to basic education, adjustments to prepayment claims, and more in-depth individual education for vendors who have errors on more than a fifth of their claims. The effort follows a Health and Human Services report that found skilled nursing facilities had the highest rate of improper payments, with nearly a quarter of those linked to insufficient documentation.

We haven’t seen anything like this in the recent past, at least not in the past 10 years, said Stacy Baker, OTR/L, RAC-CT, director of audit services for Proactive LTC Consulting. But it’s no surprise to see this industry surveyed and educated. Looking back at SBB Medicare mispayment data, we’ve never seen NFS mispayment rates this high and almost doubled since the 2021 report.

Improper payments have increased nearly 10% since 2020, according to data from the Complete Error Rate Reports. Credit: Proactive LTC Consulting.

That rate stood at 15.1% in 2022, nearly double the rate of 7.79% in 2021. A CMS report blamed the missing documentation on case-mix group members. Baker heralded the new initiative as an attempt to improve poor billing practices that emerged with the implementation of the patient-driven payment model.

But the improper payments can’t be blamed solely on the PDPM, said Alicia Cantinieri BSN, MDS vice president of policy and education for Zimmet Health Services.

That’s probably not the whole reason, he said in a webinar earlier this month.

He noted that areas of risk that could move suppliers to the fore of the audit process include past performance, such as a history of Additional Documentation Requests (or ADRs); frequent errors in the GG section, which establishes payment rates for the physical, occupational and nursing groups; diagnosis without medical record to support inclusion of MDS; and even unreadable RN signatures.

Reviews will be conducted on an upfront payment basis, unless the supplier requests a review after payment due to a financial charge. To prepare, Baker said, vendors should review their triple-check process to ensure a clean and robust claims process is in place.

Keep in mind that there are many low-risk fruits for payment errors aside from PDPM accuracy, such as but not limited to SNF-compliant certificates and certificates and medical oversight records, Baker added. These components should also be included in the triple-check process.

The CMG for each HIPPS code must also be clearly supported to validate the claim, he added.

While this audit won’t be as intrusive as some, suppliers should still take steps to prepare.

MACs will complete one round of survey and education for each vendor, instead of the usual three potential rounds as per their traditional TPE program, aimed at surveying and educating [and] the statement will be based on any errors identified, Cantinieri explained.

Baker said it’s a good idea for suppliers to start analyzing data and conducting internal audits. Some EMR software offers the ability to see PDPM data items against peers, and Zimmet offers a service that allows vendors to see their own risk score.

Vendors can also review their Program for Evaluating Payment Patterns Electronic Report (PEPPER), to see any abnormal billing patterns, Baker added.

Furthermore. Baker offered these tips for effective ADR response:

  • Develop a process and team now. Assign responsibilities for duties such as, but not limited to: identifying ADR requests, ensuring timely response to deadlines, gathering medical records and documents required to support the HIPPS Code, and reviewing the package for completeness.
  • Organize documentation for easy contractor review by labeling critical sections such as medical orders, MDS assessments, GG section documentation, and more.
  • Allow sufficient time for staff with MDS coding and clinical experience to review the statement and documentation for accuracy and to write a defensive brief if possible.
  • Keep a copy of the entire package provided to MAC in case of appeals.
  • Document and maintain records/receipts of timely submission of ADR following contractor guidelines.

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