Updated: May 23, 2020
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 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.”
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 e