Ask the payment expert about ... probe and educate reviews

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Patricia Boyer, MSN, NHA, RN
Patricia Boyer, MSN, NHA, RN

Are the probe and educate reviews occurring only in home health agencies or in skilled nursing facilities as well?

Although the Centers for Medicare & Medicaid Services already has conducted two rounds of probe and educate reviews in home health agencies, SNFs are not exempt for the newest cycle, which rolled out on Oct. 1, 2017. We already have seen a number of SNFs starting to have requests for records.

The target appears to be the RU RUG Category. You will receive a letter alerting you if you are being targeted.

This targeted probe and educate will continue for three rounds for those facilities that do not achieve a 15% or lower payment error rate.

You may appeal any denial. However, a win on appeal will not improve your error rate. You may elect to receive education before another round begins. If, after the third probe, the error rate is greater than 15%, the SNF will be referred to CMS for further action, including extrapolation, 100% pre-payment review, ZPIC or UPIC reviews.

Prepare for this now. You can review your latest PEPPER report and/or your monthly RUGs levels to see if you are an outlier that might be targeted.

Medical necessity of care is a focus. Make sure you have a triple-check process in place so you know that your claims are submitted correctly.

Now is the time to designate a person who is in charge of paper flow of additional development requests (ADRs). Get assistance. Medical review at this time is very specialized. An expert will assist you in gathering the right information, identifying all records that meet the requirements and submitting a letter of justification. This is not an easy process. 

Remember, these are pre-payment reviews. That means you do not get paid until you prove your case.

Please send your payment-related questions to Patricia Boyer at