What Medicare Contractors Are Looking For
5/1/2012
Liles Parker, a law firm specializing in health care regulatory compliance, has found that audits of skilled nursing facilities (SNFs) are likely to focus on the following issues:
- Proper Resource Utilization Group (RUG) Placement. SNF care must be provided at the appropriate level. This means that all services are necessary and reasonable and information entered on all minimum data set 3.0 entries for each beneficiary is complete and accurate. Contractors will closely scrutinize all RUG assignments, particularly those falling under the “ultra-high” therapy category.
- Necessity and Reasonableness of Therapy Care. All therapy services must be consistent with the nature and severity of the beneficiary’s illness or injury. In many instances, contractors may question the therapy modalities provided to a beneficiary, the amount of therapy a beneficiary receives, or even the activities in which a beneficiary participates during therapy.
- Provision of Skilled Care. All care provided by a SNF must be “skilled,” meaning that it can only be safely or effectively provided by technical or professional personnel, such as nurses or therapists. Contractors will often conclude that skilled care is not supported by documentation that is vague, generic, or repetitive.
- Review of Medical Documentation. Providers should review their medical documentation and related policies to ensure that, at a minimum, all of the elements and requirements discussed above are adequately addressed.