When SNF whistleblowers call me, they are being pressured to do something
they know is wrong, like write down extra minutes of therapy, or continue
therapy even after a patient no longer needs it. They want to stop the
fraud, but many of them have a question:
Why?
Why does my SNF not want me to discontinue therapy even when I know the patient
does not need it anymore?
Why does my boss want me to write down more minutes of therapy than I am actually giving?
I am in the middle of a series of blogs that I wrote just for them, to
help them understand the
why behind the fraud they see at work every day. Today I will explain why
some SNFs push for more minutes of therapy, without regard to what the
patient needs.
A SNF May Push You to Add Minutes of Therapy Because It Wants to Charge
Medicare More
In earlier blog entries, I explained that at the beginning of treatment,
the SNF fills out a minimum data set, or MDS, to assess the amount of
treatment each patient will need. Based on the number of minutes of therapy,
patients are grouped into “RUG” categories and then sub-divided
into payment categories, ranging from “ultra high” to “low”,
based on the number of minutes of therapy that the SNF expects the patient
will receive. You can read more about the
MDS and the RUG categories in my last blog entry,
Helping Whistleblowers Stop SNF Fraud: How SNF Billing Works. The amount that the SNF gets paid depends on the patient’s category
and subcategory.
How Much More Are We Talking About? A Lot.
The SNF gets the same amount for every patient in a given category and
subcategory. For example, according to a
CMS Transparency Data report, in 2013, a SNF was paid an average of $492 a day for each patient with
ADL 6-10 that was placed in the Ultra-High Rehab category RUB. But the
SNF received an average of $336 a day for patients with ADL 6-10 who were
classified in the “Very High” Category and $283 a day for
patients in the “High” category. Over the course of treatment,
the SNF on average received $12,239 for an “Ultra-High” patient,
$5835 for a “Very High” patient, and $4083 for a patient at
the “High” level.
A matter of a few minutes’ less therapy can make a big financial
difference to the SNF. For example, if a patient receives 400 minutes
of physical therapy and 320 minutes of occupational therapy, the patient
has 720 therapy minutes and will be classified into the maximum RUG rate,
“Ultra High”. But if the patient’s therapy drops by
even 1 minute, the patient drops into the “Very High” category,
and the SNF is paid substantially less for treating that patient.
A SNF May Push You to Continue Unnecessary Therapy So That It Can Charge
Medicare More
A patient’s MDS is a work in progress. Using the actual minutes of
treatment the patient has received, the SNF updates the MDS — and
the RUG rate — after the patient has received 5, 14, 30, 60 and
90 treatments.
See Long-Term Care Facility Resident Assessment Instrument 3.0 User’s
Manual, DHS CMS, version 1.13 at page 2-62 (Oct. 2015). Additionally,
the SNF has to make periodic reassessments when there is a "Change
of Therapy" (COT). These reassessments are known as OMRAs (“Other
Medicare Required Assessment”).
At each update, the SNF looks back at how many minutes of treatment the
patient has actually received, and adjusts the RUG rate to match the actual
number of minutes of therapy.
If a patient completes a certain type of therapy (say, speech pathology),
the SNF may have to reclassify the patient into a lower RUG category.
When a patient drops into a lower reimbursement category, the SNF gets
less money from Medicare.
If you are getting pressured to add therapy minutes or provide unnecessary
therapy, you may be able to file a whistleblower suit under the False
Claims Act (“FCA”). If you win, you can get a percentage of
the amount the SNF pays back to the Government.
Contact us today to learn more about FCA lawsuits.