On August 14th, Christina Bruenderman, Director of Denials and Appeals, gave us insight on what we’ve learned since the SNF 5-Claim Probes and what we can expect from CMS going forward. Here’s a quick recap of what was covered—from initial goals, to the current status, and what SNFs should prepare for next.
The SNF 5-Claim Probes launched June 5, 2023, and was designed by CMS to educate providers on documentation and proper coding on the MDS.
During the 5-Claim Probes, we found that MACs consistently focused on several common issues
during these reviews:
- Documentation didn’t support level, HIPPS recoded
- HIPPS was recoded to match repository
- No certification/recertification
- Documentation submitted is insufficient for services billed
- No documentation received
As of June 30, 2025, the SNF 5-Claim Probe has ended, but that doesn’t mean audits are over. CMS has announced that those with an error rate between 60-100% will be prioritized for a TPE, Targeted Probe and Educate review.
The TPE program is a deeper review, with up to three rounds of auditing with 20-40 claims selected each round. Key takeaways include:
- If your error rate from the TPE is under 20%, you pass the round and exit the TPE cycle.
- If your error rate is over 20%, you then undergo education and have 45 days to improve before the next round.
- After 3 rounds, CMS may escalate to pre-payment review or another TPE cycle.
To prepare for these audits, it’s best to monitor your mail and MAC portals for TPE notifications and letters. Be sure you’re reviewing the documentation thoroughly and submitting the documentation timely – submitting early can also be to your benefit.
While the 5-Claim Probe is over, the path to compliance continues. Understanding the TPE process and staying proactive with documentation can help your facility avoid more intensive audits.
Missed us live? Check out our full webinar below.
