CMS Targeted Reviews: What You Need to Know

Posted by Kelly Cooney

| Skilled Nursing Facilities Trends FAQs

In today’s digital age, many industries are benefiting from advanced tools and data in order to increase the efficiency of their operations, and aggregate statistics into key trends. This is especially true for the Centers for Medicare and Medicaid Services (CMS) and their Medicare Administrative Contractors (MACs). 

Here at Therapy Specialists, we’re finding that these MACs are more active this year with targeted reviews of therapy providers, because of the sheer volume of information they have at their disposal. With the information, we're seeing a new series of trends impacting how rehabilitation facilities are servicing their patients, and how they are complying with billing and service regulations.

When you consider the amount of information contained within tools such as PEPPER, CASPER, quality measures and the five star rating system, it’s easy to see why CMS and MACs have become more precise.

For facilities, it means you can likely expect an uptick of inquires. It's usually in the form of direct mail education letters, which are sent in order to determine whether the care that’s being provided meets the criteria for a skilled service or whether your care team is following proper procedures and protocols.       

Beyond skilled services, MACs may inquire into specific billing practices through the Target Probe Educate process (TPE). Kelly Cooney, Vice President of Compliance and Training here at Therapy Specialists, remarks, “In that case, the MAC would target request records, and then based on how those records stack up, they might deny or pay those claims. Then, they would educate the provider, and mandate that the provider goes through another round until they get to a certain level of proficiency.”

Discover 6 trends affecting rehabilitation care

Other third party agencies and quality contractors, such as Livanta, are increasing their number of audits as well. We’ve spoken with a handful of providers that have received letters asking for verification of their facility’s notices of non-coverage.    

Finally, we’ve also noticed an increase in education letters when a provider’s data looks outside the norm compared to their peers. These instances are meant to serve as an early notice from contractors. They are not accusing the facility of conducting an improper billing practice, for example, but they are advising providers to double check their billing data in order to verify they are doing it the right way.

The good news for therapy facilities is that MACs are more transparent about the specific trends that they’re following. Furthermore, they are communicating that activity ahead of time.

As a provider, here are the steps you should take to ensure that you don’t get tripped up during these targeted reviews:

  • Start by communicating the importance of these education and notification letters with your team, especially with the person responsible for getting and dispersing your mail. Some of the letters have rather tight turnaround times, so failing to open and respond to it quickly can have enormous consequences.  
  • Know your outliers on CASPER, PEPPER, etc.  Assess them as a part of your QA process.      
  • It’s critical that facilities consider the impact that these letters can have on your reimbursement and ultimately, your cash flow.  If you end up with a target probe education letter and you have a lot of denials you have to go through, it will potentially impact your cash flow.  As a result, they could pull more claims for pre-payment review. And then review those and pay or not pay them. Either way, there's potential for delay.
  • It’s equally as important to assess your options when responding to the letters. In some cases, we’ve had partners that thought they needed to send an entire chart, but only really needed to send a copy of their notice of Medicare non-coverage. Some of the requested information is even optional. When in doubt, we encourage facilities to call the phone number on the letter and double check that you know exactly what the Medicare contractor is requesting. By sending in more information than what is required, you’re opening yourself up to further audits.   

Want to learn more? Download our Industry Trends white paper to discover solutions to the most common challenges facing the rehabilitation and therapy care industry.  

Author Bio:

Kelly has twenty years of experience in the senior living industry including management positions in operations as well as clinical support for single site, multi-site, and multi-state organizations. She advocates for superior patient care, a supportive and positive work environment for staff, and cooperative partnership with customers and associates. Kelly is a long-standing member of the American Speech-Language- Hearing Association (ASHA), and most recently, received her certification in healthcare compliance (CHC). Kelly also serves as the President for NARA, the National Association of Rehab Providers and Agencies.