Reg's Blog

Senior and Post-Acute Healthcare News and Topics

SNFs, Therapy Contracts and Fraud: Redux

Yes another SNF, another therapy contract and more fraud settlements.  The only thing that isn’t different is the contractor – RehabCare once again (a coincidence?…not likely). In news released late last week, a Maine SNF settled with the Department of Justice for $1.2 million, allegations of improper Medicare billings for “unnecessary, inflated, and unreasonable” therapy services.  As in the other cases I have covered herein, the therapy services provided at Ross Manor (the SNF) were through a contract with a division of RehabCare. Again, because the overbillings for inappropriate care and/or service are made by the SNF to Medicare under Part A, the liability for the improper payments and thus all remedies, lies with the SNF – not RehabCare.

In their statement, the parent of Ross Manor, First Atlantic Corporation stated that,”Throughout this matter, Ross Manor has worked with the government to understand where it can exercise more oversight of the billing and record-keeping practices of its contractors.” Not to belabor a point but REALLY? The concepts regarding SNF liability for contractor behavior and how to audit and prevent fraud aren’t complicated or difficult  For (likely) the final time, I will reiterate the issues and the processes that encapsulate the SNF/Therapy contractor/fraud issues and how to avoid the same.

  • Under Medicare, the SNF is the PROVIDER – not the therapy company/contractor.  Therefore, any claims submitted to Medicare are submitted by the SNF regardless of who provided the service.  If the claims are fraudulent, the SNF is responsible, not the contractor that provided the service, for repayment and any applicable fines, remedies, etc.  SNFs are free to contract with anyone or entity to  provide skilled nursing services (as defined in the federal Conditions of Participation) but in so doing, as the SNF is the provider, it cannot escape the False Claims liability for claims made to the federal government.  The therapy contractor does not bill the government – the SNF does.  The expectation is that the claim is lawful, correct, and for medically necessary and proper care.
  • The SNF must therefore, provide oversight to assure that all claims are proper and that the care was necessary and legitimate.  How? I recommend the following steps.
    • Contract with an external consultant knowledgeable in therapy and Medicare billing and periodically, audit your therapy contractor.  Review the provision of care, the documentation, and the billing/claims.  For SNFs that don’t know or have connections to such a consultant, feel free to contact me – I DO!
    • Institute a triple-check process for Medicare billing, each month.  This process requires certain parties to each Medicare claim to participate in a review methodology before claims are submitted.  Again, readers who need a triple-check format/framework, contact me and I will provide one at no charge.
    • Benchmark your MDS utilization and review it against regional and local data.  Comparatively, the utilization by RUG, length of stay, and thus Medicare per diem should follow regional and local trends.  If not, an explanation and inquiry is warranted.
    • Utilize your QAPI program to track care outcomes and Medicare related MDS data.  Monitor and follow this data to assure that care is proper and documentation consistent.
    • Institute a weekly Clinical Review program to monitor resident care progress (MDS changes, therapy progress, wounds, falls, discharges, hospitalizations, etc.).  Readers who need help here, contact me.
    • Finally, have MDS certified staff on site and actively involved in the final review and submission of all Medicare claims.  This staff must be employed by the facility, properly trained, and non-financially incented to any reimbursement goals or targets.

Last, I have a few current watch targets and tips for SNFs that use therapy contractors and/or are in the process of bidding or renewing a therapy contract.

  • Watch staff productivity and time – anything above 80% is a red flag.  Demand pay records and time sheets.
  • No resident on admission should immediately be placed into all three therapy disciplines.  I see this a lot and it is an outright harbinger of fraud.  Therapy, like any other service, must be justified by an evaluation, an order, and a treatment plan.  If every resident receives all three (speech, PT, OT), something is amiss.
  • Be wary of Speech being justified for demented residents as “cognitive retraining”.  This is frequently to almost always, a non-justifiable service and one that has no recognized diagnostic correlation or outcome measurement when the underlying disease is dementia. Cognitive retraining makes sense for neurological damage due to head injuries, strokes, etc. but is unwarranted as I see it (often) applied for dementia in an SNF.
  • Be wary of the Ultra High over-utilization.  Be particularly wary of the tendency to routine code to the RUG.  Make sure someone is keenly watching the ADL scoring here and how the minutes are justified.
  • Review your contract and look carefully at the Indemnification Clause(s).  Know your exposure should a False Claims circumstance arise or simpler, a billing audit/probe.  The contract likely (unless you negotiated it differently or had me do it) will only have the therapy company liable for the cost of therapy, not the loss of the Medicare revenue in total.  SNFs have huge exposure here.
  • If you are presently entertaining a contract or renewal, make sure you memorialize any promises made during the “courtship” or “proposal” phase in the final agreement.  I watch SNFs consistently bamboozled with false promises and specious claims of success, support, etc. the same of which never show in “writing” in the final agreement.  Make sure everything is in writing.  For help and a format for contracting, contact me

I do offer/provide numerous tools, forms, etc. free of charge to any reader who contacts me.  I also provide references to vetted, trustworthy sources for services upon request.  To contact me, go to the author page on this site (contact info), comment to a post or e-mail me at hislop3@msn.com.  If you comment to a post and want me to contact you, please leave valid contact information – can’t help without it.

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April 7, 2015 - Posted by | Skilled Nursing | , , , , , , ,

6 Comments »

  1. I lead a group of not-for-profit CCRC Rehab Directors and I would like to bring your “triple check” billing framework to my rehab focus group meeting, can you plese send it to me? My group would be interested in using.

    Comment by Valarie Boughman | April 7, 2015 | Reply

    • Valarie:

      On its way. Watch your e-mail.

      Reg

      Comment by Reg Hislop III | April 8, 2015 | Reply

  2. I appreciated your comments. Please send me your triple check steps.

    Comment by Lyle Townsend | April 8, 2015 | Reply

  3. I would like a copy of your triple check steps, thanks!

    Comment by Josh | April 8, 2015 | Reply

  4. Would like a copy of your triple check steps also, thank you

    Comment by Fax 585 377-0013 | April 10, 2015 | Reply

  5. I also would like a copy of Triple Checks. Thanks in advance.

    Comment by Monica Newbery | April 13, 2015 | Reply


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