OIG Releases “Questionable Billing By Skilled Nursing Facilities” Report

Recently, the Office of Inspector General (OIG) released a report focusing on skilled nursing facilities’ (SNFs) billing practices for Medicare Part A payments. The report, “Questionable Billing By Skilled Nursing Facilities,” found that between 2006 – 2008, SNFs increasingly billed for higher paying Resource Utilization Groups (RUGs)—the classification groups of Medicare beneficiaries, based on care and resource needs—even though beneficiaries’ diagnoses at admission remained the same. It also found that for-profit SNFs were more likely than nonprofit SNFs to bill for higher paying RUGs.

The findings of the OIG report speak to the increasing medical complexity of patients receiving post-acute care in our nation’s nursing and rehabilitation facilities. A key driver of this increase in medical complexity is that these facilities are now the dominant provider of post-hospitalization services in the Medicare program. Take, for example, the findings of the 2009 Annual Quality Report:

• In 2006, hospitals discharged approximately 4 million Medicare cases to post-acute settings, of which over 50 percent went to nursing and rehabilitation facilities.
  
• From 2000 to 2006, there has been a 15 percent increase in the share of Medicare patients admitted to nursing and rehabilitation facilities. These post-hospitalization patients have a wide range of medical and rehabilitation needs.
  
• The percent of nursing facility patients receiving rehabilitative care increased from 77 percent in 2003 to 81 percent in 2005 and to 87 percent in 2007.

According to the 2010 report, over 50 percent of Medicare patients treated in nursing facilities have a “major extreme severity of illness,” and nursing facilities provide care to these patients in the lowest-cost institutional setting. In addition, since 2003, there has been an annual increase in the percentage of Medicare beneficiaries discharged to the community in 100 days.

Because the patient population consists of more medically complex patients, their care is placed in a higher RUG designation. Moving forward into 2011, AHCA/NCAL will continue to work cooperatively with providers, lawmakers and the regulatory community to ensure that positive trends, like increasing the number of patients that return home, continue to advance.

Guest Post: Changing the “Rodney Dangerfield” of Health Care

Robert Van Dyk

December 22, 2010
By: Robert Van Dyk, Chair, AHCA Board of Governors

Reflecting on the many accomplishments we achieved this past year, I am more determined than ever to change the outdated perceptions that still persist in our nation's capital and across the country. We've made progress to be sure; yet, our commitment to quality and care of our aging society has been largely overlooked. As I told AHCA/NCAL members at our annual convention, our profession is seen as the "Rodney Dangerfield" of health care… we get no respect.

Although many of us have devoted our lives to understanding and providing the care America’s seniors need, the long term and post-acute care sector does not receive the attention it deserves. While others have a seat at the health care table, we’re on the menu. Perhaps this is because policymakers in Washington, DC, as well as the general public, know very little about what we do. They don’t know that the care hospitals provide on a Thursday for about $3,000, we provide for $400 on a Friday, Saturday and Sunday. And while health care reform will deliver 32 million newly insured customers to hospitals, pharmaceutical companies and others across the health care spectrum, long term and post-acute care will not benefit from such an increase.

As I see it, our dilemma is two-fold - how do we secure our seat at the table, and how do we get policymakers to understand that funding is not just about payment, it’s about people? To me, the answers are rooted in one, simple word - respect.

The work long term and post-acute care providers do each day should command the same level of respect so readily given to our colleagues in hospitals and other health care settings. After all, today's nursing and rehabilitative facility provides the same kind of care available only in hospitals some 20 years ago. Unfortunately, our image has not kept pace with our capacity to provide care. So, we need to bring the public and Congress up to speed.

When we hear policymakers in Washington or back home refer to us as "just business owners,” we need to tell them that we're so much more. In fact, long term and post-acute care isn't about us. It’s about the people we care for, the staff we employ and the families who rely on us to be there for their loved ones and for them.

Changing a decades-old perception is hard work, and AHCA/NCAL cannot do it alone. It will take effort and we will need our colleagues, our patients, residents, staff and family members to back it up. The start of a new year, and a new decade seems like the perfect time to take on such a daunting task. I look forward to sharing much more about this challenge as we usher in 2011.

Guest Post: What's in Store for QIS and MDS 3.0?

December 20, 2010
By: Dr. Andy Kramer, University of Colorado

In case you were wondering, the new minimum data set (MDS) 3.0 will not impact the performance of the Quality Improvement Survey (QIS). However, there are some aspects of the QIS treatment of MDS data that will remain the same going forward and some that will change temporarily.

New QIS software, implemented in November, will still generate random resident census samples and admission samples for the QIS process based on MDS data. Surveyors will continue to require from the nursing facility an alphabetical resident census list of all residents who are in the facility, including those who may be in the hospital or out on a home visit. They will also require the list of recent admissions.

Surveyors will also continue to reconcile the software-generated random sample of residents with the alphabetical resident census and new admission list to finalize their samples for survey.
What will change, temporarily, is that the QIS software will not calculate or utilize the 44 Quality of Care and Life Indicators (QCLI) that are derived from MDS data. However, almost every Care Area has QCLIs mapped to it that originate from one or more of the onsite assessments that are conducted during Stage 1.

For example, the Pressure Ulcer Care Area currently has seven QCLIs that are calculated from Staff Interviews, Census Sample Record Reviews, Admission Sample Record Reviews, and MDS. Only two of these are calculated from the MDS items, so the remaining five pressure ulcer QCLIs will be utilized during QIS surveys.

The calculation and use of QCLIs based solely on MDS will be on hold until sufficient numbers of MDS 3.0 assessments have been submitted by nursing facilities. Thus, although MDS QCLIs will temporarily not be used to determine triggered Care Areas for a Stage 2 in-depth investigation, these care areas will be included in QIS because of the QCLIs from other sources. Some of the MDS QCLIs that can be calculated from MDS 3.0 data are expected to be used in QIS beginning in early 2011.

Victory: “Doc Fix” Bill Repeals RUG-IV Delay and Extends Therapy Caps Exceptions Process

December 17, 2010

This week, President Obama signed into law the Medicare and Medicaid Extenders Act of 2010 (H.R. 4994), which contains the repeal of the RUG-IV implementation delay and an extension of the therapy exceptions process until December 31, 2011. AHCA/NCAL applauds both Congress and the President for addressing these critical issues before the end of the year.

More importantly, we applaud the work of the long term and post acute care community. Your calls, letters and emails made a difference, and we can truly say that high quality patient care is preserved thanks to your work.

Other important components of the new law include the extensions of the Medicaid Qualifying Individual Program and the Medicaid Transitional Medical Assistance Program until December 31, 2011. The Qualifying Individual Program permits Medicaid to cover the Part B premiums for those Medicare beneficiaries with incomes between 120% and 135% of the poverty level. The Transitional Medical Assistance enables Medicaid beneficiaries to maintain their coverage as their incomes increase due to changes in employment. 

For more information on the bill, read our complete summary.

Finding the Right Care Fit

December 14, 2010

A recent story by NPR reported that currently, adults ages 31 to 64 comprise about 14 percent of residents  in nursing homes. This is not surprising given the increasing diversity of today’s resident population. Nursing and rehabilitation facilities (often referred to as nursing homes) no longer care for only the elderly or chronically ill. They also care for individuals requiring intensive physical rehabilitation, which are a large part of that 14 percent. The article also offers a glimpse into the challenges faced by younger individuals living at home who need long term care and services over an extended period of time.

The dynamics of care selection are well known in the long term and post acute care profession, but not necessarily by the general public. For example, when deciding where to receive care, the individual’s needs must come first. Do they require 24 hour care (which a nursing facility offers), or only assistance with activities of daily living? Answering these questions before making decisions is critical to finding the right care fit. When considering home care, it’s also important to consider whether or not the community has programs in place and resources available. In the NPR story, AHCA’s Janice Zalen and University of Maryland professor Nancy Miller point out that many community-based programs present their own challenges. In addition, state funding and support for home care continues to lag due to economic conditions.

This reinforces the important role of nursing and rehabilitation facilities in today’s society: all care services under one roof, with the goal of returning home. These facilities provide the kind of care that was once only available only in the hospital. Patients with hip and knee replacements now may recuperate from surgery in a facility where they receive the skilled nursing and rehabilitative care they need before returning home – frequently, about a month after surgery.

Guest Post: Paybacks To CMS Loom As Providers Adjust To MDS 3.0

December 2, 2010
By: John Sheridan, President, eHealth Solutions

MDS coordinators are extremely busy now adapting to the demanding requirements of MDS 3.0. It’s a new way of doing business. The new resource utilization group (RUG) IV categories include new clinical rules and require better documentation and attention to the voice of the resident than did the predecessor MDS 2.0.

All of us in long term and post-acute care are working diligently to serve residents, improve compliance, and identify and treat resident and patient needs. Now that the implementation date has come and gone, there are new challenges facing nursing facility providers. Looming on the horizon are possible “take backs” of any RUG-IV payments made to providers versus the RUG-53 hybrid grouper. The Centers for Medicare & Medicaid Services (CMS) is required to use the grouper to calculate payments, but it has not yet implemented. In case you haven’t yet heard, Congress delayed the implementation of RUG-IV until Oct. 1, 2011—one year later than the agency had initially planned for.

As CMS develops the RUG-53 hybrid payment process, the fiscal year 2011 payments are being paid with a budget-neutral RUG-IV system. In the meantime, nursing home advocates are lobbying to get Congress to move the implementation back to Oct. 1, 2010, which will serve to avert the mess of sorting out payments under hybrid-53 process.

If RUG-IV implementation is not rolled back, CMS will be required to recapture some reimbursement monies made to facilities under the hybrid-53 grouper but corrected under the RUG-IV. Those who are not prepared to measure and manage therapy may face this. Providers who prepare now by reducing concurrent therapy and boosting group and individual therapy will be less likely to get a “take back” notice.

If you want to avoid or reduce the possibility of returning monies to CMS, make time to forecast therapy minutes based on your history of Medicare days by rehab level and plan for an increase of individual therapy. This may mean adding more therapists to the payroll. Calculating these minutes is a fairly easy task and is explained in this month’s Provider magazine, page 49. There you will find out how to make these calculations and compare reimbursements under each of the RUG payment processes.

Some Help from the Experts: MDS 3.0

December 1, 2010

As providers are bustling about to adapt to the new MDS 3.0 requirements, AHCA continues to provide regular updates and tips in Capitol Connection, our members-only news publication;  Provider, a national publication from long term care professionals; and our interactive website. Most recently we’ve been in communication with CMS on the various issues related to MDS 3.0 transmission, validation and error reports, RUG scores, and Section Q. According to CMS, the majority of the persistent transmission and validation report issues are related to vendor software.

AHCA has consolidated the information received from CMS into one concise document. Here you can find details on key MDS 3.0 websites, Section Q, common error messages, technical issues and survey concerns.

During the month of December we’ll be featuring a series of guest posts on MDS 3.0 implementation from John Sheridan, President of eHealth Data Solutions. John has over 30 years of experience in the health care industry as a strategic advisor, analyst and entrepreneur serving hospital, physician and long term care professionals. We’ll also feature posts from Dr. Andy Kramer, a long term care researcher and professor of medicine at the University of Colorado.

Have questions or comments on your MDS 3.0 transition? Feel free to share them below.