The Axiom Advisor

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April 2016 Client Update

RACs to review Specific Rehab RUGs, new Rule On Medicare Overpayments, and Healthnet CCI Interim Rate Processing Update.

1. RACs to review Rehab RUGs when RU minutes were between 720 and 730 and RV minutes were between 500 and 510 on MDS used for billing.

CMS has released a new SNF Payment Public Use File that reports information on RUG utilization for 2013.  The report focuses on the fact that therapy minutes usually add up to exactly 720 minutes or between 720 and 730 for the Rehab Ultra High RUG and between 500 and 510 minutes for the Rehab Very High RUG category.

CMS is concerned that reimbursement may be the driving provision of therapy instead of the resident needs.  Therefore, CMS has instructed the Recovery Auditors (RACs) to investigate this issue.  

Are your Rehab RUGs usually within 10 minutes of the baseline qualifications for the RUG???

2. Final rule governing ACA requirement to identify and return overpayments to CMS within 60 days was published recently in the Federal Register. The rule will become effective and enforceable on March 14, 2016. 

Of key importance to operators, we note the the 10-year look back period for identifying overpayments included in the proposed rule from 2012 has been trimmed to 6 years. Note, however, that the standard for identifying overpayments, which in turn initiates the 60-day period for repayment of any such overpayment is quite low. An overpayment is "when a person has or, through the exercise of reasonable diligence would have, determined that the person has received an overpayment". As a result, we are advising operators to review their compliance plans and specifically the audit functions within those plans accordingly.

3. No need for operators to re-bill Healthnet to recover retro rate increases:

This has been a hot topic. Healthnet at one point issued guidance to operators that they were to re-bill to claim increases from interim rates. This would have created extra work on the front end and complicated AR balances on the back end.

Through the diligent efforts of Axiom Healthcare Group, we have received confirmation that once final rates are released Healthnet will re-process claims through their own internal system, without the need for operators to re-bill. We will have more updates on this as they become available.

As always, don't hesitate to contact us with any questions.