The Axiom Advisor

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December 2010 OIG Report

Questionable Billing Practices by Skilled Nursing Facilities.

All SNF Providers need to read and understand the OIG report issued in late December, 2010. This report makes it very clear that the OIG believes that SNFs are billing inappropriately and are being overpaid. When the OIG believes that to be true, SNF providers are wise to evaluate their situation relative to the OIG concerns. The following are excerpts from the OIG report:

 . . . an OIG report found that 26% of claims submitted by SNFs were not supported by the medical record, representing over $500 MILLION in potential overpayments . . .

 . . . the Medicare Payment Advisory Commission has raised concerns about SNFs improperly billing for THERAPY to obtain additional Medicare payments . . . 

These are very serious allegations. It does not matter whether they are true or not. The OIG and other government agencies will pursue what they believe to be the remedy for the inappropriate billing they believe exists. All SNFs will be impacted by this.

The OIG goes on to make some additional statements including:

  • "From 2006 to 2008 SNFs increasingly billed for higher paying RUGs, even though beneficiary characteristics remained largely unchanged"
  •  "For-Profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs"

The OIG also gives SNFs a strong indication of the specific issues they will focus on. In other words if your SNF has any of the following characteristics you are in danger of being investigated:

  • Do you bill more frequently for higher RUGs than other SNFs?
  •  Is your Length of Stay for Medicare Patients longer than other SNFs?
  •  Do you bill for more therapy RUGs (especially the ultra high level) than other SNFs?

If you observe any of these issues in your SNF you should examine your Medicare billing practices very closely. In fact ALL SNFs should take a detailed look at their Medicare billing practices to help ensure compliance. 

 We recommend the following specific actions:

  • Complete an analysis of the Medicare claims you submit (at least on a sample basis) each month.
  • Hire an independent, qualified clinical expert to examine a sample of your Medicare claims (preferably on a quarterly basis).
  • Have ALL of your licensed Nurses and licensed Therapists read and understand Chapter 8 of the Medicare Benefit Policy Manual.
  • Have ALL of your licensed Nurses and licensed Therapists take another MDS 3.0 course.
  • Have the appropriate, qualified individual complete an analysis of the clinical documentation in your charts.
  • Follow this analysis with the appropriate in-services on documentation for Medicare coverage.

These actions will help make certain that you are making the appropriate coverage decisions and billing properly. In addition, since ALL SNFs must be prepared for audits and investigations, this effort will help ensure that you do not have to pay back money when you are investigated.

For a direct link to the OIG report click here.