News, Payment/economy, Skilled Nursing Facility

CMS orders post-pay audit of SNF PPS claims

The Supplemental Medical Review Contractor (SMRC) is charged with conducting nationwide medical review as directed by the Centers for Medicare & Medicaid Services (CMS). Topics and timeframes for these reviews are dictated by CMS and are chosen to address specific agency interests regarding coverage, coding, payment, and billing practices.

On March 17, 2017, SMRC announced that CMS directed the review team to conduct a post-pay audit of SNF PPS claims under project number Y4P0445. This project reviews SNFs’ documentation of Medicare beneficiaries’ care to ensure that documentation demonstrates why a skilled service is needed. Four factors must be met, as outlined on the SMRC website, in order for SNF care to be covered by Medicare:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services
  • The patient requires these skilled services on a daily basis
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity

Providers chosen for this post-payment medical review of SNF therapy services should be aware that they may receive an additional document request letter (ADR) from the SMRC contractor, rather than the regional MAC. An example of the ADR letter is posted on SMRC’s website. Late submissions or non-response to ADRs will result in the initiation of claim adjustments or recoupment be the MACs.

For more information about other SMRC ongoing projects, click here.