SNF Audits Announced by CMS

This week, CMS posted information on two new CMS directed medical review audits of SNF PPS claims.  The first is a pre-pay audit limited to the CMS J5 Jurisdiction (IA, KS, MO, NE, and national), while the second is a national post-pay audit.  Please email Dan Ciolek, AHCA Associate VP, Therapy Advocacy with questions.

Medicare J5 MAC Announces Pre-Pay Audits for Rehab Ultra High RUGs in IA, KS, MO, NE, National

On April 4, 2017, Wisconsin Physician Services Government Health Administrators (WPS GHA), a Medicare Administrative Contractor (MAC) for the Centers for Medicare and Medicaid Services (CMS), announced that they will be conducting prepayment service specific complex medical reviews of Inpatient SNF services for providers in the J5 Jurisdiction.

The J5 Jurisdiction encompasses SNFs that submit claims from Iowa, Kansas, Missouri, Nebraska, and other national providers.

The article states that “A prepay edit will be initiated with reason code 51SNF for J5 claims with dates of service on or after April 1, 2016, meeting the following criteria:

  • Original inpatient claims
  • Type of bill – 21X
  • Containing ultra-high rehabilitation RUGs”

On the WPS GHA website, they state that use data analysis to identify services at risk for potential errors. When the data analysis supports the potential for high risk billing practices within a specific service, a prepayment edit is then initiated to identify potential errors or incorrect billing of the service. The goal of Medical Review is to reduce the claims payment error rate by identifying patterns of inappropriate billing through:

  • Identifying patterns of inappropriate billing through data analysis
  • Conducting medical review of claims
  • Educating providers on identified issues

Please note that while WPS GHA is also the CMS MAC for the J8 Jurisdiction (which covers Indiana and Michigan), AHCA has confirmed that this new audit announcement only applies to providers that submit claims as J5 providers.

Contact dciolek@ahca.org if there are questions.

Medicare SMRC Announces CMS Directed SNF PPS Post-Pay Audit

Strategic Health Solutions, LLC (SHS) is the Centers for Medicare and Medicaid Services (CMS) Supplemental Medical Review Contractor (SMRC) that is charged with conducting nationwide medical review as directed by CMS to address specific agency interests regarding coverage, coding, payment, and billing practices.   Recently, the SHS website announced that on March 17, 2017, CMS directed the SMRC to conduct a post-pay audit of SNF PPS claims under project number Y4P0445.  SNF providers selected for this audit may receive an Additional Documentation Request (ADR) letter directly from the SMRC contractor instead of the regional MAC.  Here is an example ADR letter that was posted on the SMRC website.  Traditionally, the SMRC audits are limited in scale so providers are not over-burdened with a large number of ADRs, but it is extremely important not to overlook or ignore the ADR requests, as late submission or non-response will result in the initiation of claim adjustments or recoupment by the MACs.

Contact dciolek@ahca.org if there are questions.


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