|
|
08/29/2007
The Risk of Enhancing Rehab Scores
by: Marc N. Zimmet
“Acuity driven” healthcare payment systems often experience “case-mix creep.” As providers become familiar with a system, reported acuity (and associated payment) increases. The Medicare Part A skilled nursing facility prospective payment system (“SNF PPS”) is no exception to this rule. Since the onset of the system eight years ago, the intensity of reported Resource Utilization Group (“RUG”) scores has increased nearly every quarter. In fact, many providers now “capture” most of their patients at the highest paying “rehab RUG” scores. The one negative aspect of dramatic rate increases is the associated escalation of “medical necessity” audits from Medicare Fiscal Intermediaries (“FIs”) and other contractors.
Medicare is concerned with this trend, as discussed in the 2007 MedPAC Report to Congress. “The current design of SNF PPS… encourages providers to furnish therapy even when it is of little or no value.” This incentive has contributed to case-mix creep, and FIs have taken notice.
As consultants, we have noted a marked increase in the number of therapy claims subjected to post-payment review. More of these cases are being denied or “trickled down” to a lower paying score.
Facilities that capture a disproportionate share of residents in “Ultra High” and “Very High” rehab RUGs are at greater risk of review. Therefore, SNFs providing this “subacute” level of care should routinely review the “profile” of claims submitted for payment.
Intermediaries do not conduct “random” reviews. Instead, they rely on various data mining techniques that highlight aberrant patterns within the UB-04. In other words, they search for claims that do not fit the expected “profile” for therapy RUGs.
A “Claims Profile Analysis” is a relatively simple review of UB-04 data that compares the intensity of rehab utilization to the following factors on a “per case” basis:
• Age of resident
• Diagnosis
• Length of time of rehab
• Discharge location
• Cognitive ability
• ADL score progress
Inconsistencies/concerns are easy to identify. As an extreme example, a Florida SNF (that was forced to repay over $700,000 of Medicare reimbursement subsequent to an Office of Inspector General audit) provided Ultra High therapy to an 83-year-old resident diagnosed with end-stage Alzheimer’s disease with severe behavior issues. The medical reviewers concluded that the patient was unable to participate meaningfully in rehabilitation therapy because of cognitive impairments and the claim was denied. This represents a “red flag” that could have been identified through a basic pre-billing review process.
While it is tempting to provide additional therapy to drive reimbursement, increased RUG scores may heighten your audit exposure. A simple review of your UB-04s can reveal potential threats to compliance. ZHSG can assist you in identifying if your facility is at risk and design appropriate strategies to circumvent a potential problem with Medicare. Please feel free to call me at (732) 970-0733 to discuss how we can help your facility.
>> Back to all Hot Topics. |
|
