This week, the Office of Inspector General (OIG) released a report: Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More than a Billion Dollars in 2009. The OIG found that 25% of SNF claims submitted in 2009 were in error, amounting to $1.5 billion in overpayments. To read the full report, click here.
What the OIG found
The erroneous 25% of claims include:
- 20.3%: Claims with an inaccurate RUG (upcoded). In 57% of these claims, SNFs provided more therapy on the MDS than was documented in the medical record; and 25% of these claims involved therapy listed in the medical record that was not reasonable and necessary
- 2.5%: Claims with an inaccurate RUG (downcoded)
- 2.1%: Claims that did not meet Medicare coverage requirements (e.g. no physician order)
The OIG also found that 47% of claims involved inaccurate MDS information. The primary reporting error was the amount of therapy received or needed, followed by special care, ADLs, oral/nutrition status, and skin conditions/treatment.
It is clear that the government is increasing its focus on therapy services provided in nursing facilities--and therapy services should be a high, and possibly the highest, compliance priority for SNFs.
What to expect
The OIG recommended, and CMS agreed with, the following government action plan:
- Increase and expand review of SNF claims
- Identify SNFs that are billing for higher paying RUGs
- Monitor compliance with new therapy assessments
- Change the method for determining how much therapy is needed
- Improve the accuracy of MDS items
- Follow up on the SNFs that billed in error
MPA TIPS: How to prepare
- Compare your RUG distribution to your historical average and to regional benchmarks, in order to identify any over-utilization patterns
- Conduct an audit of your billing accuracy to identify your most frequent billing errors
- Use sample audits to determine if your MDS information is backed by medical record documentation
- Review therapy treatment plans and goals for appropriateness
- Strengthen your partnership with your therapy provider in order to identify and address any RUG assignment inaccuracies