SNF Post Pay Audits to Begin

April 17, 2017
Rick Gawenda

Skilled Nursing Facilities (SNFs) have been put on notice. On March 17, 2017, the Supplemental Medical Review Contractor (SMRC) announced the Centers for Medicare and Medicaid Services (CMS) has directed them to conduct a post-pay audit of SNF PPS claims.

Per the SMRC, care in a SNF is covered if all of the following four factors are met:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see 30.2–30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services
  • The patient requires these skilled services on a daily basis (30.6)
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity (30)

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