“Finally Friday!” CMS Sics the RACs on SNF Billing

FRIDAY March 11, 2016:

“CMS Goes Sniffing RUGs and More

sniff

Don’t be surprised… it’s in their nature.

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THIS WEEK, we want to talk about more evidence that CMS and other payors are focusing on more than inpatient, now. CMS just posted Skilled Nursing Facility utilization and payment data, providing a public database with information on services provided to Medicare beneficiaries by skilled nursing facilities (SNFs). The files include data on utilization, payments, and submitted charges organized by provider, state, and resource utilization group (RUG). It is based on 15,055 SNFs, over 2.5 million stays, and almost $27 billion in Medicare payments for 2013. (SNFs are paid via 58 RUGs, using a per diem payment based on a Minimum Data Set comprehensive assessment, for a specified minimum number of minutes per week, as established for each RUG. Most of these claims are filed under Part A, although providers must use Part B if the beneficiary has exhausted their Part A benefits.)

Why is CMS doing this? It’s not just to make the data public. Apparently, they hope to actually affect provider efficiency. Somehow. Sorta. I actually think it’s a veiled threat to providers, but that’s me.

This is how I imagine they act when reviewing all those RU and RV claims. Probably before they even get the records, eh?

This is how I imagine they act when reviewing all those RU and RV claims. Probably before they even get the records, eh?

The data includes a look at payments for two categories of RUGs for patients who receive “high amounts” of therapy: Ultra-High (RU) and Very High (RV) Rehabilitation RUGs. CMS claims that the current data shows an increase in the amount of therapy provided, which of course equates to higher payment for the provider. So, they say they will now “…refer this issue to the Recovery Auditor Contractors (RAC) for further investigation, and our hope is that data transparency will facilitate real changes.

PLUS – a recent OIG Report points to the “new” overall focus on other compliance issues – particularly Outpatient issues and coding validation. Sharon Easterling has been warning about this for quite some time and we’ll be going over some examples and pointers from her, as well.

In our show, we will go over:

  • SNF: Even Nursing Documentation is now critical
  • Coding Validation Review Basics
  • Looking Forward: E&M and Procedure Coding – who’s doing it for you?

So join us, share your own insights and bring your questions for us!

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