AAPACN 2025 Quality Virtual Conference Recording Bundle: Intermediate Track-2.4 SNF Audit Ready: Navigating Reviews, ADRs, and Appeals

Video Transcription

Video Summary

The video discusses Medicare reimbursement and compliance in skilled nursing facilities, emphasizing the importance of accurate MDS coding and documentation to ensure proper payment, compliance, and quality care. It explains CMS's medical review programs—including CERT, MAC, RAC, and SMRC—that audit claims for errors, improper payments, and fraud. Skilled nursing facilities have the highest Medicare error rate (17.2%), primarily due to insufficient or missing documentation. The review process evaluates claim accuracy, medical necessity, and eligibility, with reviews occurring pre- or post-payment. Facilities receive Additional Development Requests (ADRs) to submit records supporting claims, which must be carefully compiled, verified, and sent timely. The video stresses the vital roles of MDS coordinators and therapy managers in reviewing documentation, ensuring skilled care justification, and coding accuracy. If claims are denied, facilities can appeal through five escalating levels—from contractor redetermination to federal court—each with specific deadlines and requirements. Best practices include implementing compliance programs, conducting internal audits, and performing a "triple check" of claims by business, clinical, and therapy staff prior to submission. Quality Assurance and Performance Improvement (QAPI) teams should monitor medical review feedback and denials to correct documentation errors and improve compliance, thereby safeguarding reimbursement and reducing risks under the False Claims Act.

Keywords

Medicare reimbursement

skilled nursing facilities

MDS coding

CMS medical review programs

claim audits

documentation compliance

Additional Development Requests

claims appeal process

Quality Assurance and Performance Improvement