If previous Recovery Auditor (RA) experiences in the skilled nursing facility (SNF) setting are any indicator (think about the ongoing manual medical review audits occurring), then the new review announced by the Centers for Medicare & Medicaid Services (CMS) could be devastating to providers, as it involves SNFs’ main revenue stream in many cases.  

According to the announcement, RAs will be reviewing RU and RV resource utilization groups (RUGs) in cases for which the total therapy minutes provided in the lookback period were within 10 minutes of the minimum necessary to achieve the RUG. 

As news of this spreads, much discussion and debate will occur to determine how such reviews will impact providers’ finances, SNF operations, and therapy delivery in the SNF setting. 

In the two-plus weeks following this announcement, I have had multiple conversations with providers in order to share how they should be preparing for the onslaught of additional documentation requests (ADRs) and how to mitigate risk going forward. Below you will find my most frequent recommendations:

  1. Prepare: We know the Recovery Auditors are coming. And as you know from previous experience, the paperwork shuffle can be quite daunting and burdensome. It would be much easier if you already had the paperwork collected and ready when you receive an ADR. After analyzing your RUGs below, you will know which Assessment Reference Dates (ARDs) meet the criteria in question. Start pulling documents now that you will use to defend those claims.
  2. Analyze: In my opinion, knowledge truly is power. I recommend going through your software and identifying all the ARDs for which the patient achieved an RU or RV RUG when the total therapy minutes were within 10 minutes of the minimum required to achieve the RUG. Then, assign the appropriate RUG dollars for each day the particular assessment covered in order to identify your potential exposure. In doing this type of analysis, I always want to know what the potential outcomes may be, and you should too. Obviously, if all of the identified dollars at risk are denied, then  that is one outcome to consider. And this is a possibility if the Recovery Auditor reviews your documentation and decides that the documentation does not justify or support that the services provided were medically necessary. There are other possible outcomes, such as the RA downcoding all RUGs in question, so your reimbursement could be moved down one rehab RUG. I would calculate the dollars that you might owe based on the downcoded RUGs to determine what this potential payback risk looks like. Another possibility is that your therapists are excellent documenters and the documentation supports the services provided, meaning the RA will agree that the services your facility provided were appropriate. That is a best-case scenario! But by knowing the possibilities, it will help you understand what truly is at stake – not just now, but also going forward.
  3. Educate: As I indicated in my original RACmonitor article, education is key. It has been common practice for some providers to bill for services planned versus services rendered in an effort to not provide “overage” minutes. The industry loosely defines overage minutes as those that were provided over the minimum required to achieve the RUG. Another definition could be interpreted as minutes provided that were not reimbursable. In an effort to minimize the number of non-reimbursable minutes provided (which is essentially giving away therapy for free), some providers choose to bill for the planned minutes instead of the actual minutes. An example of what this may look like is the following: the plan was for 50 minutes of physical therapy (PT) today, but 54 minutes of therapy were actually provided. In this case, the PT should bill the 54 minutes; however, some providers are billing for 50 minutes, for reasons stated above. This practice has to stop. We must be billing for the services we are providing – nothing more, nothing less.

    Also, be sure that you do not direct your therapists to just “move the bar.” What I mean by this is that directing them to provide 511 minutes for RV or 731 minutes for RU is no different than directing them to do 500 or 720, respectively. The point here is that we need to be providing clinically appropriate care that meets the needs of the patient and that is individual to that patient’s unique needs, and does not follow predetermined minutes.

  4. Mitigate: You can’t change the past. What’s done is done, and whatever your potential liability will be, it is just that – your potential liability. Starting today, how do you mitigate your risk related to this issue going forward? Mitigation starts with education, as previously described. Also, you must ensure that your team is billing for truly Medicare-billable services, and that the time with each patient is properly documented. Sometimes it is helpful for therapists to be reminded that in order for reimbursement to occur, all Medicare-billable services must meet certain criteria: the therapy and time spent with the patient must require the skills of a therapist, must be medically necessary, and must be provided in such a way that it meets each individual patient’s needs. I recommend that you question your therapists regularly – not in an accusatory manner, but in a way that helps clarify what they are doing and why they are doing it. If you are not currently in the habit of having these conversations with your team regularly, then before you start questioning them now, you may want to have a conversation explaining why you will be asking more questions. You will also want to review each ARD when it happens (possibly during your PPS meeting). As you are getting close to a patient’s ARD, ask your therapist/therapy manager if it is appropriate for this patient to have more or less therapy, and make sure they can justify their answer with medical necessity. While ongoing chart auditing should already be part of your quality assurance program, I would pay close attention to those charts that we now know will be pulled by the Recovery Auditors. Additionally, you should bring in third-party, nonbiased auditors regularly to ensure that the documentation being captured actually demonstrates medically necessary care. You then should go back and provide more education based on what you find in the charts. 

During this process, you may identify issues of a legal nature that you were unaware existed. If that is the case, do not hesitate in contacting counsel, as additional analysis may need to be performed under privilege.  

Ensuring that your therapy team is providing individualized, medically necessary care AND documenting it will be the key difference between those provider organizations that successfully navigate the most recent Recovery Auditor issues and those that could find themselves in a precarious financial situation. 

As always, RACmonitor will keep you informed as this story develops. 

About the Author

Mark McDavid, OTR, RAC-CT is the president of Seagrove Rehab Consulting + Education where he assists in-house and contract therapy clients with compliance issues and therapy operations. He serves on AANAC’s Expert Advisory Panel and as a board member-at-large for the National Association of Rehabilitation Providers and Agencies. 

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