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  • SNF Use of Highest Therapy Categories to be Investigated by RACs

    New data now available from the Centers for Medicare and Medicaid Services (CMS) seem to back up allegations that many skilled nursing facilities (SNFs) are inappropriately using "ultra-high" (RU) and "very high" (RV) rehabilitation categories to increase their payments—and improve their bottom lines. The findings have prompted CMS to turn over the issue to recovery audit contractors (RACs).

    On March 9, CMS released a new public use file on SNF utilization in 2013, representing more than $27 billion in Medicare payments and approximately 2.5 million stays among 15,055 facilities. The file breaks down the numbers in multiple ways, allowing users to look at payments arranged by resource utilization groups (RUGs), average payment amount per beneficiary, geographic regions, and therapy minutes. The data were based on SNF Part A institutional claims.

    According to CMS, the data on the use of RV and RU therapy contain a telling detail: namely a significant number of patients whose therapy time was within 10 minutes of the lowest possible threshold that would still allow the SNF to get the RV or RU payments. The report shows that in 2013, more than 1 in 5 SNFs reported 75% or more of their RV or RU minutes in amounts just over the required minimums (between 500 and 510 minutes per week for RV 720-730 minutes for RU).

    Overall, RU received $16.6 billion in 2013, while RV was associated with $5.5 billion in payments.

    "CMS strives to ensure that patient need, rather than payment system incentives, are driving the provision of therapy services," said Shantanu Agrawal, deputy administrator for program integrity and director of the CMS Center for Program Integrity in a news release. Agrawal added that concerns over the ways in which RV and RU were being used have prompted CMS to refer the issue to the RACs for investigation. "Our hope is that data transparency will facilitate real changes," Agrawal said.

    The RAC referral adds to what have been difficult times for SNFs over the past few months, as the press, the US Department of Justice, and the US Department of Health and Human Services have focused attention on SNF billing practices.

    Among other SNF-related data in the file:

    • The average standardized payment per stay for all SNFs was $10,919, with an average stay of 28 days.
    • The states with the highest average standardized payment per stay were Indiana ($12,406), Texas ($12,064), and California ($11,862).
    • States in the southwest had "notably high" percentages of RU assessments that fell just inside the thresholds, according to CMS, but so did California, Nevada, and "a few Southeastern states."


    • they just figured it out after over 25 years?

      Posted by Leah Hoyer -> ?KW^> on 3/15/2016 8:26 PM

    • Abuse of physical therapy is everywhere. That's what happens when you give power to someone who has a conflict of interest or who isn't a physical therapist.

      Posted by Burton Ford on 3/15/2016 8:38 PM

    • Abuse is still very rampant. I am so glad I no longer work in a SNF. I was very disappointed with a lot of things at my previous facility. It was a very unfortunate experience. I learned that in the end that for-profit organizations are in it for the money.

      Posted by george shaw on 3/16/2016 4:20 PM

    • I worked as an OT for 10 years and 1/2 my time was spent in SNFS...When I first started practicing, I was "asked" to improve adl training with people who had alzheimers through adl retraining...I was very vocal about how that was unethical (and I meant fraudulent), so I didn't last very long in that facility. Years later, medicare wouldn't reimburse for such services...I wonder why. Later, I worked in quite a few places that "expected" their clients to get the best therapy through excessive therapy that many couldn't tolerate...although some could. the government needs to hire ots and pts who are willing to "watch" the system, and the ultra high minutes need to correspond with progressive levels of function. On a side note, my father was in acute care in a hospital in Ohio, sveral months ago. I got chummy with the PT, and I asked what productivity he had to have. ..100% was his response...there's no way in hell you can achieve that!!! I worked in s cute care. The highest level on the best day is 75%.

      Posted by Annette Fleisher on 3/16/2016 11:11 PM

    • All I see here is the government trying to save money, not what is really necessary for patient needs. Very high only allows less than 42 minutes of treatment if only 2 disciplines are involved over a 6 day period. Maybe the CMS should have themselves audited.

      Posted by Kenneth Mars on 3/17/2016 8:25 AM

    • We need therapists to determine RUG levels.

      Posted by Justin Johnson -> @GT_?N on 3/17/2016 9:06 AM

    • Sometimes services provided by PT/OT/ST that should really have been done by LNA's. In this way, facilities understaff LNA's, bill medicare to have a therapist do it, and make double the money. Other situations, like being asked to see a patient for 120 minutes of PT, on a dialysis day, clearly just to make a RUG level. It is sad how our profession is used in this setting.

      Posted by Brent on 3/17/2016 6:39 PM

    • I've been a treating PTA in SNF'S for almost 20 years. The productivity keeps getting higher (last place I worked was 95%) and everyone was seen for the highest RUG and part B's were seen for no more than 53 minutes. The contract therapy companies promise the SNF'S the moon in order to get and keep the contract. But everything CMS changes the structure somehow they will find a way to still get the highest reimbursement and keep them on caseload forever. What ever happened to caring about the patient first? All they want to do is line their dirty little pockets.

      Posted by Cantdoitanymore on 3/19/2016 9:13 AM

    • Ms Hoyer's post above says it all. Appalling it has taken them this long to discover this. Hundreds of millions of dollars have been paid out in the last 2 decades.

      Posted by David Ravnikar on 3/19/2016 10:38 PM

    • I get so frustrated hearing from homecare patients upon their release from a SNF complain of being “placed on this little hand cycle and told to ride for 15 minutes, and there’s nothing even wrong with my arms” or “boy they really gave mom a lot of therapy at the rehab unit, we don’t understand why your PTA is only here 30 or 40 minutes 2 days a week.” I want to tell them it’s called maximizing reimbursement and explain the RUG system to them but don’t have the time, effort, or patience anymore. I’m also tired of hearing about needing to get 50 more minutes on Mr. or Mrs. So-and-so to get them into the Very High category. Every time M/C changes the reimbursement models non-therapy and some therapist administrators find a way to unnecessarily get as many Medicare dollars as possible out of each case. It can turn a person bitter and callous about the whole rehab system and can down right piss a person off as a tax payer. Evaluate and treat AS INDICATED should be the SNF mantra as well as in all other settings. Maximize outcomes in as few visits, or treatments, as possible, this shows that the science is progressing and making advances.

      Posted by Jeff Womack on 3/21/2016 9:43 AM

    • As an SLP that has only worked in SNFs for the past 16 years and has been fortunate to work in a patient centered not-for-profit organization, I am often sickened by what I hear from "for profit" entities. Not only are people pushed to get excessive minutes, but they very often have NO supplies or equipment... one thing my organization does is invest in materials and equipment so quality services can be provided.

      Posted by Edgar V. Clark, M. Ed., CCC/SLP on 4/23/2016 2:53 PM

    • In truth, the only way to achieve the expected 90-95% productivity levels in order not to be sent home, or worse, fired, is to commit Medicare fraud. It's no use telling anyone that the patient cannot handle the minutes, is sick, or actively DYING! The office manager punches in the number of minutes needed for UH. The program manager will lose his bonus, or worse, get himself fired if he doesn't make his unrealistic financial budget, and the corporate owners vacation on the Riviera. I will be taking the useless mandatory ethics course, again , next year. WHEN is the APTA going to address this and support their members??. Our licences are on the line

      Posted by Anne f on 12/28/2016 8:53 PM

    • I hear that within a year there will be no more RUG levels. I work in a place where the therapist decide what the patient can tolerate, but at times still feel pressured to meet the RUG level in the event the patient was sick one day and you have to make up all the minutes the next day.

      Posted by Sally on 7/18/2017 1:32 PM

    • What do you expect from a system that puts a corporation between the provider and the recipient of a medical service?

      Posted by Ronald Balistreri on 11/25/2018 7:33 PM

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