The goal of the claims review program is purportedly a combination of recoupment when payment is too high combined with education. It is likely that providers with prior bad history of ADR (Additional Documentation Requests) or probes, if their performance on this review is poor, will receive additional follow-up attention. The claim reviews are pre-payment vs. post-payment.

From the Medicare FFS (Fee for Service) Improper Payment Report (all provider types) for 2022, I included two pages with data, illustrative of the SNF improper payment issue and the reasons why. The pages are located here:2022 Improper Payment Report – SNF The most common cause of impropriety was insufficient documentation.  Some of this continues to relate to PDPM as SNFs in many regards, lag in terms of MDS coding knowledge and billing education.  COVID did not help.  Other issues are as simple as improper certification times, illegible signatures, improper Section GG (therapy coding) and improper diagnosis codes.   Per CMS, the improper payment amount for 2022 is estimated to be $5.8 billion.

My caution here for all post-acute providers but especially for SNFs and Home Health Agencies, claims audits are here to stay.  According to Altarum’s Health Economic Sector Index, SNFs spending increased 11.6% YoY (March) and Home Health spending increased 8.7%.  Outlays, within programs with known billing impropriety issues, beget claims reviews. The full Altarum brief is here: https://altarum.org/publications/may-2023-health-sector-economic-indicators-briefs

As I have written before, compliance is a fairly new requirement for SNFs.  Within the ethics and compliance Condition of Participation found at 483.85 (F- 895) SNFs must, among a number of requirements, implement a system (reasonable with policies and procedures) to find and correct, improper billing practices such that the same, could be fraudulent or could be in violation of federal law.  The last element, violation of federal law is tricky.  It is against the law to bill Medicare for care that is rendered improperly or is sub-standard.  Technically, care provided to a resident, billed to Medicare, later determined to be harmful via a survey (G level violation or worse) is a violation of federal law.  A decent overview of the compliance requirement is available here ComplianceandEthics 483.85

Essentially, post-acute care providers, particularly HHAs and SNFs need to develop a comprehensive ethics and compliance program that INCLUDES regular claim audits.  The difficulty, however, is for the audits to be useful and proper, the same should be conducted by an independent auditor.  This can be costly and often, non-helpful when the auditor is not uniquely familiar to normal provider operations and typical survey and certification processes.   The goal of the audit process is detection and then, education.  Incorporated properly within a well-developed ethics and compliance framework, the audits can be completed efficiently and wrapped within a proper QAPI (Quality Assurance) function.  Done right, the ethics and compliance program dovetails into a QAPI program and vice-versa.  This reduces separate work, enhances process improvement, focuses on resident/patient care and how the same is effectively provided, properly documented, and properly billed.  Watch this site for more on this topic and for additional tools that I have developed and effectively used with H2 Healthcare clients.

A bit of travel awaits so I will not offer new posts/updates until next week.  Until then, Vaya con Dios!