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My law firm represent whistleblowers who know about Medicare fraud. When
I get calls from skilled nursing facility (“SNF”) employees,
they often know that they are being asked to do something wrong, like
write down that they gave more minutes of therapy than they really did.
Often, though, they are not familiar with the billing side, and they do
not know why the SNF is pushing them to do something they clearly see is wrong.

I wrote this series of blogs to help my clients understand how SNF billing
works. Today’s blog is about the big picture of how the billing
gets done under Part A. In later entries, I’ll talk about how the
fraud works.

Minimum Data Set and the RUG

In order to bill Medicare, the skilled nursing facility fills out a “Minimum
Data Set” or “MDS” form for each patient. Based on the
MDS, the patients are grouped into one of 8 RUG categories. Two RUG categories
apply to patients who need therapy: “Rehab Plus Extensive”
and “Rehab”. You can learn more about the MDS and RUG rates
by reading my last blog entry,
How SNF Fraud Works: Billing Under Part A Inpatient Therapy.

Reimbursement Rates from Ultra High to Low

The major RUG categories are then divided into five subcategories, based
primarily on the number of minutes of therapy provided to the patient.
When a therapist fills out the MDS, one of the things she does is assess
how many minutes of treatment she believes the patient will need, for
purposes of classifying the patient at a reimbursement rate somewhere
between “Low” and “Ultra High”:

Ultra High (RU)

(NOTE: The “RU” level should not be confused with the “RUG” rate.)

* 720 minutes/week of therapy (minimum)

* At least 2 disciplines

* One discipline at least 5 days/week

Very High (RV)

* 500 minutes/week of therapy (minimum)

* One discipline at least 5 days/week

High (RH)

*325 minutes/week of therapy (minimum)

* One discipline at least 5 days/week

Medium (RM)

*150 minutes/week of therapy (minimum)

* 5 days across 3 disciplines

Low

*45 minutes/week of therapy (minimum)

* over at least 3 days

* nursing rehab 6 days/week, 2 activities

See63 Fed. Reg. 25,252 at 26,262 (May 12, 1998).

Medicare pays a SNF more money for treating a patient in the “Ultra
High” category than it does for a patient in the “Very High”
category, so a SNF has a financial incentive to maximize the number of
patients who get put into “Ultra High” and “Very High”
categories.

The Ultra High RUG is Supposed to be Rare

In theory, very few patients should be in the “ultra-high”
category. According to Medicare, the Ultra High ("RU") RUG level
is "intended to apply only to the most complex cases requiring rehabilitative
therapy well above the average amount of service time." 63 Fed. Reg.
26,252, 26,258 (May 12, 1998).

No Rounding: Counting the Exact Minutes of Therapy

For purposes of selecting the right category, the SNF
can count every minute of therapy that the patient receives, whether for speech/pathology, physical or occupational
therapy, but the therapy minutes are countedexactly, and not rounded up or down: “Do not ‘round’ all treatments to 15-minute increments,
but rather record the actual treatment time. Also do not record as “units”
of treatment, instead of minutes.” Local Coverage Determination
for Outpatient Physical and Occupational Therapy Services, National Government
Services, Inc. (L26884) (rev. 2/1/2011),
https://apps.ngsmedicare.com/lcd/LCD_L26884.htm. Thus, under Part A, 8 minutes of therapy are recorded as 8 minutes (which
is different from the way therapy minutes are counted under Part B).

You may be able to stop SNF fraud and get a percentage of what the SNF
reimburses to the Government.
Contact us to learn more about False Claims Act lawsuits.