The rate of improper payments is rising, particularly among skilled nursing providers, a veteran regulatory expert said on Wednesday. She highlighted areas that providers often overlook when submitting claims and how they can work to avoid claim denials.

The improper pay rate across SNFs jumped from 13.8% in 2023 to 17.2% last year, resulting in more facilities receiving invites from the Centers for Medicare & Medicaid Services to participate in its mandatory Targeted Probe and Educate program.

TPE aims to help lower claim denial rates, but providers receiving those anxiety-inducing notification letters from the agency could be asking: How did I get here?

“It might sound very nice that CMS is going to help the facility improve, but it’s not a tea party,” Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet Healthcare Services Group, said during a webinar. “TPE is a serious thing. If you’ve been selected to be audited for this, how do you get chosen? Well, topics are based on data analysis. They focus on providers and suppliers who have been identified through data analysis as being a potential risk to the Medicare trust fund or who significantly vary in their billing from their peers.”

Some common themes that trigger an audit by a Medicare Administrative Contractor, Cantinieri said, are unusual billing practices, such as labeling all residents with the same primary diagnosis code, high facility claim error rates, and entering items and services that have high national error rates.

Common causes

Of all documentation errors, there’s one that makes up more than 50% of those flagged by CMS, Cantinieri said.

“If the physician signed their name but didn’t date the certification … denied. If the physician’s handwriting is completely illegible and we don’t send the signature log to show that that’s the physician’s signature … denied,” she affirmed. “If the physician signed it late with no attestation for the reason why, also denied. Really pay attention to your certifications because it hits two out of four of the common reasons for claim errors.”

Providers also must ensure their claims don’t include what may be deemed medically unnecessary treatments, Cantinieri said.

She detailed one facility’s paperwork where diabetes had been coded as an active diagnosis in one resident’s file. The patient, however, was not receiving insulin or any oral agents, as well as no labs, monitoring, treatment or medication. Stroke was also coded as an active diagnosis because the resident had experienced one previously. But the record did not detail how long ago it had occurred and did not note any residual effects.

In this case, the conditions were not considered active diagnoses, she said, leading to claim denials.

But the provider was able to appeal the denial after submitting corrected documentation. It recouped nearly $15,000 — but its claim error rate was still negatively impacted, Cantinieri noted.

An extra set of eyes

Operators can stop denials before they happen by revisiting the basics, Cantienieri offered. This includes triple-checking claims and understanding risks.

“In preventing claim denial, you need to know your risks. How do your charts look? Are you doing internal audits? And those may or may not be a good idea,” she explained. “It’s definitely not a good idea for someone to audit the MDS that they completed because I know from experience, I’m not likely to recognize my own mistakes, especially if it was something I didn’t understand how to code.”

Appointing an objective, third-party auditor to review Medicare claims is another effective method, she offered, as they won’t have inside knowledge of residents or their conditions and will solely be checking for an accurate medical record.

And third-parties may not only check for what MACs will be reviewing with the TPE, but also for what other CMS auditors could be eyeing, too.

With updated CMS guidance having taken effect Monday, outside auditors could present a great opportunity for operators to get off on the right foot, she added.