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Indiana had the highest average standardized Medicare payment in 2013, followed by Texas and California, according to The Skilled Nursing Facility Utilization and Payment Public Use File, released March 9, 2016. The national average length of stay was 28 days with an average standardized payment amount per stay of $10,919.

States with the 2013 highest average standardized Medicare payment were Indiana ($12,406), Texas ($12,064), and California ($11,862). Other Midwestern states data totals included Illinois ($11,525), Ohio ($10,901), and Kentucky ($10,153). The use of Ultra High therapy RUGs accounted for the highest percentage of total therapy days and the highest Medicare payments to SNFs, totaling more than $16.6 billion dollars. The data set used in this report included billing information from 15,055 SNF part A institutional claims from over 2.5 million stays, with Medicare payments of nearly $27 billion in calendar year 2013. 502 Indiana, 711 Illinois, 934 Ohio, and 285 Kentucky providers were included in this publicly available data sample.

Skilled Nursing Facility Average Standardized Payment per Stay, by State, 2013

Source: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-09.html

Minimum Minutes

Also highlighted in the release, is the use of “minimum minutes” thresholds to achieve the RU or RV RUG. Minimum minutes is defined by CMS as providing therapy time within 10 minutes of the total required to achieve the rehab RUG. In plain language, the report scrutinizes the practice of tightly case managing therapy time based on rehab RUG level criteria. Specific findings reported included:

51 percent of all RV assessments showed therapy provided between 500 and 510 minutes.
65 percent of all RU assessments showed therapy provided between 720 and 730 minutes.
For 88 providers, all RV assessments showed therapy provided between 500 and 510 minutes.
For 215 providers, all RU assessments showed therapy provided between 720 and 730 minutes.
More than one in five providers had more than 75 percent of both RU and RV assessments that showed therapy provided within 10 minutes of the minimum threshold.
Notably, therapy provision at minimum thresholds to achieve a rehab RUG was a criticism used in the recent RehabCare Group, Inc. whistleblower lawsuit false claim allegation which lead to a $125 million settlement with the Kindred owned subsidy, plus over $8 million in settlements from providers who contracted with the therapy provider who were alleged to have provided inadequate oversight of the contract vendor’s rehabilitation services. RehabCare denied the allegations in a statement released by Kindred, but chose to settle “in order to provide clarity” for customers, shareholders and government entities.

The graphic below shows the percent of RU assessments between 720 & 730 minutes in 2013 by state:


Source: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-09.html

Provider Impact & Recommended Action Steps:

The CMS news release points to the significance of therapy program oversight and a deliberate action plan for therapy focused compliance reviews.

Prepare for RAC Reviews
“CMS strives to ensure that patient need, rather than payment system incentives, are driving the provision of therapy services,” said Shantanu Agrawal, M.D., deputy administrator for program integrity and director of the Center for Program Integrity at CMS, “These concerns have prompted us to refer this issue to the Recovery Audit Contractors (RAC) for further investigation…” (CMS news release). With a proven track record of managing large scale medical review response on behalf of providers, Proactive can assist in preparation for and an effective response to government audits.

Identify and correct RUG management process and supportive documentation vulnerabilities now through an objective external review.
With expert licensed and AANAC certified (RAC-CT) therapist consultants, Proactive is uniquely positioned to partner with therapy contract companies and SNF providers for 3rd party auditing and therapy oversight consultation. Proactive’s approach to documentation review, includes pre-billing clinical sampling and use of a 13-point chart audit process which focuses on the critical medical necessity support variables that RAC reviewers target.

Demonstrate a commitment to therapy utilization and billing accuracy through robust QAPI and SNF Compliance Program efforts.
Proactive audits are the first step in a multi-pronged approach that drives meaningful performance improvement efforts, including customized training, clinical program development and 1:1 staff coaching. Proactive reviewers have the insight and experience to promote growth in the quality of rehab skilled intervention practices, documentation improvement and clinical outcomes. Provider customized monitoring including monthly data reports, demonstrate the Proactive client provider’s dedication to rehabilitation excellence and Medicare compliance.

Analyze your facility’s recent SNF PEPPER data trends and review the PUF data release to determine if your facility was included in the 2013 sample. Determine your provision rates for therapy RUG distribution and minimum threshold minutes compared to peers.
Request a comprehensive action plan from Proactive in response to SNF PEPPER outlier areas and PUF data release findings.

Register to attend the upcoming webinar “A Compliance Focused Response to SNF PEPPER” on May 5th from 10:30 am – 12:00 pm.
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Proactive Medical Review

812-471-7777 | amartin@proactivemedicalreview.com