My older brother and I were experts in sibling combat. We fought and wrestled, pinning each other down or locking in submission holds. Victory only came when “Uncle!” was shouted in surrender.
Ever been trapped in CMS’s submission hold, feeling defeated and tempted to scream “Uncle!”? Maybe you felt that way when reading CMS transmittals 12032 and 12037, a wild ride of instructions for Medicare Administrative Contractors (MACs) and their Targeted Probe and Edit (TPE) mission on SNFs.
With rule changes, MDS tweaks, and staffing updates on the horizon, it’s like a tag team of stress. But don’t jump out of the ring! We’re the titleholders for the senior and medically fragile population, especially in small or rural communities where we keep families close and provide awesome job opportunities. We’re crucial!
Now, onto the pending TPE. MACs are about to review and adjust 5 prepayment claims and dish out education based on error rates.
So, as my colleague Susan Krall likes to say, Let’s Get to The Point (LGTTP). Train for the championship with these moves:
- Read Ashley Duggan’s Medical Review blog posts.
- Review your current skilled documentation. Teach, coach and follow-up with your team now, before MAC has you in a leglock.
- Notify your team about the review, stress the need to spot ADR requests in the billing system for quick responses, double-check the provider address to catch MAC letters, and assign a trustworthy team member to gather and share requests with the IDT promptly.
- Send the packets well within the allowable time frame.
- Ensure you have seasoned team members and alternates in place to manage the process.
- Carefully track the claims in the billing system after they are sent to identify claim remarks and adjustments as soon as possible. Do not assume your job is completed once your initial response is sent—wait for the final count!
Here’s the truth about denials: They’re often due to late responses, incomplete packets (where the info doesn’t back up the billed services), and yes, you guessed it, facilities going radio silent. So, tighten your process, alert and train your team, send timely and complete response packets to your MAC…and never cry “Uncle!”
