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Are you a whistleblower who knows about a skilled nursing facility (SNF)
that is committing fraud? I’m a lawyer who represents whistleblowers,
and I hate fraud just as much as you do!

I find that the whistleblowers who call me know that they are being asked
to do something wrong — like bill more minutes than they actually
spend with a patient — but they may not understand
why the SNF is trying to force them to do something they know isn’t
right. My goal is to help SNF employees understand why and how their bosses
are cheating Medicare so that — together — we can stop it.

In order to grasp how
SNF fraud works, my clients want to understand how billing works in the first place.

When it comes to inpatient services, a SNF bills under Medicare Part A.
To simply the billing process, Medicare does not pay a SNF an individually-calculated
amount for each and every patient. Instead, Medicare has SNFs group their
patients into categories, called Resource Utilization Groups (“RUGs”),
which are based on how much care an individual patient is likely to need.
Medicare pays a set, daily rate for each patient who is classified into
a particular RUG category.

Step 1: The SNF Fills Out a Form Called an “MDS.”

The daily rate that Medicare pays a nursing facility is scaled depending
on what type and amount of rehabilitation the beneficiary needs. When
a patient first enters a SNF, medical professionals at the SNF fill out
a lengthy form called the “Minimum Data Set” or “MDS”.

[T]he MDS 3.0 is a data collection tool that classifies beneficiaries into
groups based on the average resources needed to care for someone with
similar needs. The MDS 3.0 provides a core set of screening, clinical,
and functional status elements, including common definitions and coding
categories. It standardizes communication about resident problems and

Skilled Nursing Facility (SNF) Billing Reference, HHS CMS, ICN 006846 (Nov. 2015). That document is the basis for how a
SNF is going to charge for the patient.

Step 2: Based on the MDS, the Patient is Assigned a RUG Category and Subcategory.

Based on the data gathered in the MDS, the patients are classified into
one of eight major “RUG” categories: “The MDS contains
items that reflect the acuity level of the resident, including diagnoses,
treatments, and an evaluation of the resident’s functional status.
The MDS is used as a data collection tool to classify Medicare residents
into RUGs (Resource Utilization Groups).” Long-Term Care Facility
Resident Assessment Instrument 3.0 User’s Manual, DHS CMS, version
1.13 at page 1-7 (Oct. 2015).

Patients then are further classified into subcategories under each of the
major RUG categories. On October 1, 2010, CMS implemented “RUG-IV”,
which has 66 different subcategories.

Step 3: How SNFs Inject Fraud

When a skilled nursing facility moves a patient from one category to another,
it can generate hundreds more dollars of revenue
per patient, per billing period. SNFs sometimes pressure their employees to do things that are designed
to add just the amount of time needed to shift the payment into a higher category.

If you are dealing with a SNF that is trying to defraud the government,
contact me today — we may be able to stop the fraud!


Lee’s peers have named her a Georgia SuperLawyer every year for two decades.