Navigating the CMS 5-Claim Probe and Educate Initiative
The Centers for Medicare & Medicaid Services (CMS) launched the 5-Claim Probe and Educate initiative in 2023 and it is ongoing in 2025. This CMS Program Integrity Initiative is a targeted effort to lower the SNF improper payment rate. This program directly impacts Skilled Nursing Facilities (SNFs) by reviewing randomly selected claims and providing valuable feedback to strengthen billing practices.
What is the 5-Claim Probe and Educate Initiative?
Under this initiative, CMS reviews five claims for every Medicare-billing SNF in the country. The SNF will then be offered education to address any errors identified, helping them avoid future claim denials and adjustments. This process offers SNFs an opportunity to learn from the findings and strengthen their internal systems to avoid future issues.
Any claims for SNF services that took place on or after October 1, 2019, are eligible for the review except for those that contain a COVID-19 diagnosis, which will be excluded from this review.
Is this Review Similar to a TPE?
Similar to the current Targeted Probe and Educate (TPE) medical review strategy, the SNF 5 Claim Probe & Educate Program includes one-on-one provider education at the completion of a small sample of claim reviews. However, instead of the 1-3 rounds of review a provider receives through TPE, each SNF will undergo only 1 round of review.
- MACs will review 5 claims from each SNF.
- MACs will complete one (1) round of probe and educate for each SNF, not the potential three (3) rounds that may occur in the traditional TPE program.
- Education offered will be individualized based on the claim review errors identified in the probe. Review results letters will detail the denial rationales for each claim, as appropriate.
What Do You Do If Your Facility is Selected for the 5-Claim Probe and Educate Initiative?
Ensure that your facility staff is well informed about the procedures and expectations when a review occurs. Communicate with your therapy staff to ensure the HTS Regional Director is promptly notified. HTS partners with Proactive LTC Consulting to serve as our third-party denials management team, and once timely notice is provided, they can efficiently manage the process on our behalf.
The 5-Claim Probe and Educate initiative is a valuable opportunity for SNFs to refine their processes, reduce compliance risks, and improve the accuracy of claims. By working together, we can ensure your facility is prepared and positioned for success.
For more information or support, please reach out to your HTS Regional Director. We’re here to help you navigate this initiative with confidence.
Written by:
Sheena Mattingly, M.S., CCC-SLP, RAC-CT | Executive Vice President of Quality & Compliance, HTS
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