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  • Writer's pictureMarie

Tricked into Unethical Practices in Skilled Nursing Facility SNF?

Updated: May 23, 2020

The Scenario

In a recent Facebook group post, a member posted that “My DOR told me that we are absolutely NOT allowed to see anyone for evaluation only, we must find something to treat. Is this unethical? Am I being tricked?”

AOTA Announcement

AOTA released an announcement in April 2017 that states, “There has been increased scrutiny of skilled nursing facility (SNF) practices, particularly billing for Medicare Part A services, resulting in several lawsuits and settlements over the past 18 months.”

“Inappropriate and Potentially Unethical Practices in SNFs” is 5 pages long and I’m going to pull out the pieces you need to know about and summarize the important stuff.

What are the take home points?

“The current payment system in SNFs categorizes patients in Resource Utilization Groups (RUGs) to determine their daily Medicare rate. The number of minutes of skilled therapy plays a key role in determining the RUG level and, therefore, Medicare reimbursement. SNFs have been found to use some of the practices below to record more therapy minutes to push patients into higher RUG categories resulting in higher reimbursement.”

“Data on how many patients are in the higher RUG categories also shows an aggressive use of these categories by companies.”

Just Remember

It is critical to remember that all therapy provided must be reasonable, necessary, and skilled. These principles must guide Medicare billing in all cases.

The Official List with Notations to Help Put the Statements into Perspective

They go on to cite inappropriate practices pulled from recent settlements with SNF companies. Here is the list and in bold you will find what I think you need to know.

  • Presumptively placing all or most patients in the highest therapy reimbursement level at admission, rather than relying on individual evaluations to determine the level of care necessary to meet each patient’s clinical needs Note: Upon evaluation, it is YOUR responsibility to make a suggestion for the number of minutes that would be appropriate for the patient. Typically, the DOR sets the number of minutes high to meet the highest RUG level and then waits for you to not meet those minutes to question the lack of minutes or the need for a decrease in minutes. Tip: Be proactive! Note SOMEWHERE in your evaluation how many minutes you are recommending and the frequency to protect yourself! Notate when and what you told your DOR is your recommendation.

  • Scheduling, providing, and reporting therapy to patients even after the therapist recommends that the patient be discharged from therapy Note: Be CLEAR in your recommendations. “Preparing for discharge, patient made aware and is agreeable.” If you’re asked by your DOR to continue seeing the patient, you won’t be able to go back and edit 4 or 5 notes that keep stating discharge is this coming Friday and the patient and their family are already agreeable. Get my drift? Make it difficult.

  • Arbitrarily and without appropriate evaluation shifting the number of minutes of planned therapy among different therapy disciplines (i.e., physical, occupational, and speech) to ensure targeted therapy reimbursement levels are achieved, regardless of the clinical need Note: You should be questioning any swift changes in therapy minutes. You are responsible for their appropriate plan of care, including minutes!

2 scenarios here:

Scenario 1:

Patient has been at 45 minutes every day and today they have 90 minutes. Think: – Is my patient able to tolerate the increase in minutes? If not– document the reasons why and document that you made your DOR aware.

If my patient IS able to tolerate the increase in minutes, did I make the wrong initial recommendation of minutes? (there should be a progressive increase – not drastic!) If you made a mistake, you will need to document that you are recommending an increase in minutes and that their body and vital signs reacted appropriately. You should expect that now that they are able to tolerate 90 minutes, they will require 90 minutes from this point forward.

Scenario 2:

If you mistakenly see the patient for 90 minutes and only have 45 minutes today. Think: – Did something happen to the patient that they are no longer able to tolerate 90 minutes? Document it! – Are they tired from yesterday’s 90-minute session? Document it!

  • Providing significantly higher amounts of therapy at the very end of a therapy measurement period for the purpose of reaching the minimum number of minutes required for the highest therapy reimbursement level; called “spiking,” this enables SNFs to bill a higher RUG even though patients were receiving materially less therapy on preceding days. These patients often get exactly or barely more than the minutes required for the higher RUG. Reminder:You should be treating for the minutes YOU find appropriate. Your DOR should be choosing minutes based on YOUR recommendations.

  • Inflating initial reimbursement levels by reporting time spent on initial evaluations as therapy time in violation of the Medicare prohibition on counting initial evaluation time as therapy time; note that evaluations are required and are paid for as part of the basic component of payment to SNFs that is included in every RUG. *****Common Mistake***** If you bill 15 minutes of evaluation and 75 minutes of treatment, you NEED to be providing 75 minutes of treatment!!! Recommendations: Bill for what you did, don’t cut yourself short!  Did you educate nursing? Speak to patient about POC, frequency, STG goals, LTG goals, history, etc.?  I can’t imagine not billing a significant amount of patient education for every single evaluation. Recommendations: THOROUGHLY understand the evaluation codes that you are billing and use them APPROPRIATELY. So many therapists say, “this is what they told us to bill.”

  • Reporting that skilled therapy has been provided to patients when the patients were asleep or otherwise unable to undergo or benefit from skilled therapy

  • Reporting rounded minutes instead of reporting the actual minutes of therapy provided ***Quit this today!!

  • Aggressive therapy targets set to achieve an Ultra High RUG that are completely unrelated

to patients’ actual conditions, diagnoses, or needs Reminder: Again, document what you have recommended to the DOR

  • Frequent overriding of or ignoring therapists’ recommendations and unnecessarily delaying

patient discharges (i.e., “be creative” to find goals to keep patient in therapy) Reminder: Your notes should clearly state why and when you made your DOR aware that discharge was needed.

  • Providing patients with excessive amounts of therapy that are not medically reasonable and

necessary, and may even be harmful Think: Why is everyone at 60 minutes?

  • Instead of providing skilled rehabilitation therapy that is tailored to patients’ particular needs, routinely providing generic, non-individualized services that do not benefit patients, do not relate to occupation-based goals, and that serve primarily to inflate what is billed to Medicare/payers Think: Are you inappropriately arm biking?

  • Corporate pressure to meet Ultra High targets (to assure that a certain number or

percentage of patients get into Ultra High), undermining the clinical judgment of therapists

at the expense of SNF patients Remember: You are obligated to anonymously report.

  • Corporate pressure or retribution for lodging internal complaints or chastising or punishing

those who raise concerns; concerns are often just ignored or therapists may be fired Think: If you do make a complaint, is their record of it somewhere? Email for a paper trail.


  • “Hugging the RUG”: Patients get just enough therapy to qualify for the next highest RUG. Minutes for RUG levels are not upper limits and should not be viewed as upper limits. For example, 720 minutes is a minimum for Ultra High (RU), not a target Reminder: Self-explanatory, bill only what is needed.

  • Extending length of stay for financial reasons by strategies not directly related to therapy minutes. An example of an inappropriate company goal is increasing annual average length of stay by 2 days year over year, ignoring or overriding clinical judgment regarding when patients should be discharged, sometimes using a discharge checklist and requiring permission from supervisors or corporate to discharge. Note: Do you know what the average length of stay for each type of insurance/type of patient is? If you do not, how are you determining your long-term goals?

  • Rolling missed minutes from one day to the next in order to make up minutes and keep the patient in a higher RUG Think: Why are they able to tolerate more minutes today? And then why are they going back to the original number of minutes – what happened?

  • Electronic systems automatically populating fields with “pre-set goals” that may or may not be reflective of individual patient needs. Medicare requires that therapy be reasonable, appropriate, and skilled to meet the needs of the individual patient. Goals must be pertinent to the individual.

  • Discouraging free form notes in lieu of drop-down menus, not allowing therapists to completely/accurately capture what is happening with the patient

  • Setting patient goals that are unreasonably high, changing goals once they are achieved to keep the patient in therapy, setting goals that are not needed/wanted by the patient Think: Do I have enough time built into my day to review my notes and COTAs notes to ensure this isn’t happening?

  • Threatening patients to make them stay (i.e., falsely telling them it isn’t safe for them to go home or that they won’t qualify for home health)

  • Exhausting all 100 days of Medicare benefit when inappropriate, keeping in mind that some 100-day stays are appropriate and documentation should reflect that

  • Limiting time that therapists are allowed to spend on evaluations (i.e., 15 or 30 minutes, or directing therapists to report a fixed time such as 15 or 30 minutes for initial evaluation and falsely report additional time was spent providing therapy. ***very common

  • Providing rote, unskilled services to “get the minutes” (i.e., using arm bikes, stacking cones, assisted walking, non-individualized circuit training, low-intensity repetitive “strengthening” exercises, etc.) Think: When my patient goes from 45 minutes to 90 minutes, am I REALLY able to justify the activities I am doing to meet the minutes?

  • Inappropriately using e-stim, modalities, and/or bedside treatment to maximize the number of therapy minutes *very common

  • Inappropriately billing “patient education” during down times while the therapist is documenting, or when the patient refuses therapy **very common

  • Inappropriately using or inadequately supervising OTAs and PTAs Think: Do I know the ratio in my facility? Are my OTAs billing for time that I am not in the building/not supervising?

  • Having therapists perform, observe, or assist patients with routine activities of daily living and counting it as skilled minutes **common!

  • Inappropriately expanding individual patient treatment to 6 or 7 days rather than the 5 to get more therapy minutes and get each patient to a higher RUG

  • Creating special programs (e.g., holding a regular ice cream social billed as skilled therapy)

  • Pressuring therapists to record treatment provided according to pre-set minutes, even when patients are sick, weak, or refuse treatment Reminder: Spending time persuading them does NOT count as patient education!

  • Equating patient tolerance for therapy with need for therapy Note: If I can run a marathon, it doesn’t mean I NEED therapy.


“If you observe any of these practices, report to your compliance hotline or the HHS OIG. Report to the OIG online at or by calling 800-HHS-TIPS (800-447-8477) or TTY: 800-377-4950. Refer to the Compliance Reporting Consensus Statement (AOTA et al., 2014) for more information about reporting. The OIG will investigate, but you will not hear back from them, and your reporting will be kept confidential.”


AOTA Annoucement:

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