The erroneous 25% of claims include:

• 20.3%: Claims with an inaccurate RUG (upcoded). In 57% of these claims, SNFs provided more therapy on the MDS than was documented in the medical record; and 25% of these claims involved therapy listed in the medical record that was not reasonable and necessary
• 2.5%: Claims with an inaccurate RUG (downcoded)
• 2.1%: Claims that did not meet Medicare coverage requirements (e.g. no physician order)

The OIG also found that 47% of claims involved inaccurate MDS information. The primary reporting error was the amount of therapy received or needed, followed by special care, ADLs, oral/nutrition status, and skin conditions/treatment.

It is clear that the government is increasing its focus on therapy services provided in nursing facilities--and therapy services should be a high, and possibly the highest, compliance priority for SNFs.

What to expect

The OIG recommended, and CMS agreed with, the following government action plan: 

• Increase and expand review of SNF claims
• Identify SNFs that are billing for higher paying RUGs
• Monitor compliance with new therapy assessments
• Change the method for determining how much therapy is needed
• Improve the accuracy of MDS items
• Follow up on the SNFs that billed in error

MPA TIPS: How to prepare

• Compare your RUG distribution to your historical average and to regional benchmarks, in order to identify any over-utilization patterns
• Conduct an audit of your billing accuracy to identify your most frequent billing errors
• Use sample audits to determine if your MDS information is backed by medical record documentation
• Review therapy treatment plans and goals for appropriateness
• Strengthen your partnership with your therapy provider in order to identify and address any RUG assignment inaccuracies

MPA can help

Management Performance Associates can help you implement a compliance program or strengthen your current one. To learn more about how your compliance program can help you avoid penalties for billing and other errors, please visit our website: http://www.healthcareperformance.com, or give us a call at 314-434-4227 ext. 16.