ultra high therapy RUGs
APTA Summary of SNF Proposed Rule Now Available
APTA Summary of SNF Proposed Rule Now Available. – APTA’s summary of the proposed rule for skilled nursing facilities (SNF) for fiscal year 2012 outlines 4 major updates that will affect physical therapy—payment for group therapy, therapy student supervision, payment cuts, and other Medicare-required assessments (OMRAs). (Click link above for more)
Senior Care agrees to settlement involving Evergreen Rehab work | Tampa Bay Business Journal
Senior Care agrees to settlement involving Evergreen Rehab work | Tampa Bay Business Journal. – This article highlights two North Carolina facilities (part of a mutil-state chain) who’s therapy contractor pushed the envelope in Medicare RUG Utilization and under review was not able to prove that the services were clinically appropriate. Unfortunately, the rehab contractor’s philosophy and business practice may not be that uncommon. With the recent OIG report “Questionable Billing by Skilled Nursing Facilities”, (http://oig.hhs.gov/oei/reports/oei-02-09-00202.pdf) more scrutiny is coming. If you have high RUG Utilization levels in the Very High and Ultra High categories, you may want to have a through review of your documentation to ensure these services can be proven to be clinically appropriate. Even so, with proper documentation, you may still be at risk. The Provider in this article not only has agreed to pay a major fine, they are also under a CIA (Corporate Integrity Agreement) for the next five years.
OIG Releases New Report: Questionable Billing by Skilled Nursing Facilities
The Office of Inspector General released a new report titled “Questionable Billing by Skilled Nursing Facilities” on 12/22/10. This report will lead to further scrutiny of rehabilitation services.
Summary (from OIG website)
Skilled nursing facilities (SNF) categorize beneficiaries into resource utilization groups (RUG) based on their care and resource needs. Medicare generally pays the most for ultra high therapy RUGs. Medicare also pays more for RUGs for beneficiaries who require more assistance with certain activities of daily living, such as eating.
We found that SNFs increasingly billed Medicare for higher paying RUGs from 2006 to 2008, even though beneficiary characteristics remained largely unchanged. Specifically, we found large increases in RUGs for ultra high therapy, with payments to SNFs for ultra high therapy increasing by nearly 90 percent from 2006 to 2008, rising from $5.7 billion to $10.7 billion. In addition, RUGs for high levels of assistance with daily activities increased. We also found that for-profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs, and we found that a number of SNFs had questionable billing in 2008. Taken together, these findings raise concerns about the potentially inappropriate use of higher paying RUGs, particularly those for ultra high therapy.
We recommend that CMS: (1) monitor overall payments to SNFs and adjust rates, if necessary; (2) change the current method for determining how much therapy is needed to ensure appropriate payments; (3) strengthen monitoring of SNFs that are billing for higher paying RUGs; and (4) follow up on the SNFs identified as having questionable billing. CMS concurred with three of the four recommendations. It did not concur with the recommendation to change the current method for determining how much therapy is needed, but stated that it is committed to pursuing additional improvements to the SNF payment system.
Full report can be downloaded by clicking the following link:
http://oig.hhs.gov/oei/reports/oei-02-09-00202.pdf
Long Term Care Rehabilitation 