Medicare Compliance & Reimbursement

If you do get a notice of a probe review, don't do this.

SNF providers may not be the only ones worried about RACs on the prowl for overpayments. Numerous consultants are seeing more MAC/FI probe reviews, which they say may signal that Medicare contractors are ramping up their efforts to detect overpayments before RACs get the chance. "It could be that MACs are feeling pressure from the RAC audits" to do more post-payment reviews, which may be a self-preserving effort "to keep their contracts with CMS in good standing," surmises Sherri Robbins, RN, BSN , supervising consultant with BKD LLP in Springfield, Mo. She notes that the MAC in her region is doing more post-payment reviews, creating panic among SNF providers.

FR&R Healthcare Consulting has also been seeing quite a few probe reviews from NGS and Wisconsin Physician Services, reports Betsy Anderson, VP for the firm in Deerfield, Ill. Anderson has, in fact, recently seen several SNFs working on prepay probes. "A couple are for Part A and a few are Part B," she adds. "Sometimes it starts out with post-payment reviews, and depending on the percentage of denials, goes into prepay [ones]." It's also occurred to Atlanta consultant Darlene Greenhill that RACs could spur MACs/FIs to do more reviews. She has a client who had a recent probe review, "and the letter the facility received about the probe review said the MAC was doing 30 more of them."

Knowing that MACs/FIs may be doing more probe reviews gives you a heads up to sharpen your probe management skills.

Key point: If you get notice of a probe review, don't assume it's because you've done something wrong. "The SNF might look at its compliance procedures and determine if there was something out of the ordinary going on that might have triggered the probe," says Anderson. "Sometimes it could be higher-thanaverage utilization for a specific service or area," she says. Sometimes it might be claims errors that are occurring "maybe even in billing."

Be aware of this key difference: When faced with a RAC audit, "the provider can sometimes find out why the RAC wants to do an audit and be able to explain to the RAC what's going on in terms of why the SNF is different in some way," Anderson adds. For example, the SNF may have an intensive orthopedic rehab program that explains its higher utilization, she says. In some cases, that kind of explanation will suffice to halt the RAC review process. "But it's not going to stop the process for a probe," Anderson adds. "The MAC/FI will go ahead with the review and make sure the SNF has the documentation to support [what it has billed to Medicare]."