In an era of increasing transparency, a new report called the “Skilled Nursing Facility Utilization and Payment Public Use File” (SNF PUF) puts SNFs’ therapy utilization under the microscope. In early March, the Centers for Medicare & Medicaid Services (CMS) released the SNF PUF, which contains payment data from more than 15,000 SNFs caring for 2.5 million residents at a staggering cost of $27 billion in 2013 alone.

 

For some time, SNF providers and therapy companies have experienced the pressure of government audits for therapy practices. The SNF PUF adds fuel to the audit fire as it highlights concerns that Medicare costs are being driven by therapy volume rather than by individual patient need.

In 2013, according to the SNF PUF, Medicare reimbursed more than $21 billion for the two top-paying Resource Utilization Groups (RUGs) that SNFs use to bill Medicare—the Ultra High and Very High Rehabilitation categories.

The report explains that in order to qualify for an Ultra High (RU) Rehabilitation RUG, a resident must receive at least 720 minutes of therapy each week, among other criteria. To qualify for Very High (RV) Rehabilitation, the resident must receive at least 500 minutes of therapy each week. The criticism leveled at facilities regarding the PUF data centers around the high percentage of claims billed within 10 minutes of the residents’ achieving the RU or RV thresholds.

For example, 65 percent of all RU assessments showed therapy provided between 720 and 730 minutes. Similarly, 51 percent of all RV assessments showed therapy provided between 500 and 510 minutes. This same 10-minute pattern was followed for more than 75 percent of both RU and RV assessment claims by one in five providers.

The SNF PUF is fueling additional government scrutiny. “CMS strives to ensure that patient need, rather than payment system incentives, is driving the provision of therapy services,” says Shantanu Agrawal, MD, deputy administrator for program integrity and director of the Center for Program Integrity.

“These concerns have prompted us to refer this issue to the Recovery Auditor Contractors (RACs) for further investigation, and our hope is that data transparency will facilitate real changes.”

Can the government automatically deem it wrong if the reported minutes are within 10 minutes of achieving the RUG threshold? No. The therapy services furnished may have been what the individual resident required. However, claims and Minimum Data Set (MDS) data are often insufficient to determine medical necessity. If CMS identifies atypical utilization patterns, it may employ the tool of complex medical review to make a coverage determination.

“It is common practice for government program integrity efforts to use statistical profiling to identify patterns of service delivery that they want to investigate further,” says Dan Ciolek, associate vice president, therapy advocacy, at the American Health Care Association. “Determining the right amount of therapy to furnish to achieve a desired clinical outcome is not an exact science, but high-quality care that is well-documented should withstand the increased scrutiny announced by CMS.”

SNF leaders should respond to the emerging audit potential with a methodical, organized quality assurance plan. They can start by identifying how their facility RUG utilization stacks up on the SNF PUF. Facility-specific data can be downloaded via the SNF PUF Excel document, “Medicare Therapy Minutes Aggregate Table, CY 2013, Microsoft Excel (.xlsx).” Once facility leaders know how their facility rates, they’ll have a better idea of their risk for audit. If they find that their facility RU and RV RUG levels fall close to the RUG thresholds, they’ll know that additional action is required.

A formal Performance Improvement Project (PIP) process can be used to identify the facility’s statistics and therapy practices. Facility leaders should also discuss with the nursing and therapy teams how effectively therapy case management focuses on the individual needs of the residents.

SNF responsibilities are spelled out in a recently established corporate integrity agreement between the Office of Inspector General and a facility group, which outlines the delivery, management, and oversight that rehabilitation therapy services must have. Therapy services should:

■ Be delivered pursuant to a comprehensive assessment and individualized therapy treatment plan;

■ Be consistent with the nature and severity of the patient’s individual illness or injury;

■ Comply with accepted standards of medical practice;

■ Be reasonable in terms of duration and quantity;

■ Be reasonable and necessary given the patient’s condition and the therapy treatment plan to improve, maintain, or slow deterioration of the patient’s condition; and

■ Only include services that are inherently so complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.

A formal PIP can be used to audit a sampling of recent therapy cases to ensure that the documentation indicates the services were reasonable and necessary, they required the services of a licensed therapist, and the length of stay was appropriate given the resident’s condition.

The results of an audit will help to home in on specific training needs that facility staff may have. The PIP plan should include training and auditing to ensure accurate documentation and appropriate clinical case management.

Systems can be shored up by auditing for accurate therapy minute logs. The outcome of an accurate therapy log should be an accurate MDS. Far too many recovery audits have found discrepancies between the MDS and the therapy log.

Charted minutes must never be rounded; logs should always contain the actual minutes of therapy provided. The therapy minutes and days and the type of therapy must then be transferred accurately to the MDS. Recovery auditors have found cases where group or concurrent therapy has been incorrectly captured as individual therapy. Internal audits can help identify errors and prevent them from occurring.

Charting should include a clear description of how the services are medically necessary for the resident to maintain or improve his or her status, according to the written plan of care. Details should also be included on how the licensed therapist’s services are instrumental in meeting the resident’s treatment goal.

With the transparent information about therapy and care outcomes being broadcast to the world, it’s important to have transparency within the facility. Facility leaders must never abdicate their responsibility for oversight of therapy services to an outside therapy company. Strong coordination and collaboration between facility staff and therapist are essential to avoiding government fines.

Judi Kulus, MSN, MAT, RN, NHA, DNS-CT, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.