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We Defend Healthcare Providers Nationwide in Audits & Investigations

The Current CMS Initiative on Reducing Hospital Admissions is Here!

Reducing Hospital Admissions(April 23, 2012): According to the Director of the Centers for Medicare & Medicaid Services (CMS) Medicare-Medicaid Coordination Office, more than 1800 entities have expressed interest in a CMS initiative that will provide $128 million over 4 years to entities to reduce hospital admissions and readmissions from nursing facilities for dual-eligibles (patients with both Medicare and Medicaid coverage). According to the CMS announcement, the Agency will partner with “enhanced care & coordination providers” to implement evidence-based interventions to reduce hospitalizations. Organizations eligible to apply for these grants include physician practices, care management organizations, and other public and not-for-profit entities.

The Center for Medicare & Medicaid Innovation (CMMI) Fact Sheet lists past demonstrations that have reduced avoidable hospitalizations through the use of nurse practitioners in nursing facilities to manage residents’ medical needs. Presumably, this refers to the EverCare demonstration project which was held several years ago. Additionally, the Fact Sheet discusses strategies such as implementing quality improvement and communication tools for changes in resident status and condition. Letters of intent are due to CMMI byApril 30, and proposals are due by June 14.

Private insurers also are expected to implement a variety of partnerships and strategies with nursing homes and other post-acute providers. For example, earlier this year Aetna announced an agreement with Genesis Healthcare, a large post-acute company, to establish an incentive arrangement if the company is able to reduce hospital re-admissions.

We also anticipate a number of other types of innovative arrangements between nursing homes, insurers, and other providers and organizations, including managed care organizations, to develop strategies and incentives to provide more efficient care to post-acute patients, including managed care patients.

Healthcare LawyerMichael Cook recently presented to the American Health Lawyers Association Conference on Long Term Care and the Law on the topic of “Opportunities and Challenges to Managed Care Contracting for Post-Acute and Long Term Care Providers During and After Health Care Reform.” Providers and other entities desiring assistance in responding to incentives posited by the Affordable Care Act and CMMI should contact Michael Cook at (202) 298-8750. Michael has substantial experience in assisting post-acute providers and others in structuring innovative care delivery mechanisms to respond to the delivery systems reform incentives.  

ZPICs are Conducting SNF Medicare Audits Around the Country!

SNF Medicare audits by ZPICs are increasing. Are your Medicare claims compliant?(July 10, 2011):  In response to a report released by the Office of the Inspector General (HHS-OIG) of the Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) recently signaled that it will direct Medicare contractors to more closely scrutinize the billing patterns of skilled nursing facilities (SNFs). In fact, since HHS-OIG released its report, we have noted a dramatic increase in the number of SNF Medicare audits being performed by Zone Program Integrity Contractors (ZPICs). These audits can potentially result in extrapolated overpayments of millions dollars.  In light of these enhanced audit and enforcement efforts, it is essential that SNFs take steps to better ensure that their actions fully comply with applicable documentation, coverage and payment requirements.  Areas of particular concern identified by ZPICs have included:

I.  Areas of ZPIC Concern — Likely Focus of SNF Medicare Audits:

Certifications and Recertifications. Federal regulations require that a physician certify a patient’s need for SNF services “at the time of admission or as soon thereafter as is reasonable and practicable.” The first recertification must take place by the patient’s 14th day of SNF care, and each subsequent recertification must take place every 30 days. Providers should ensure that they conduct and document certifications and recertifications in a timely fashion. A number of contractors have refused to accept copies of physician’s orders — including orders for additional or ongoing therapy care — as a substitute for a certification or recertification.

Hospital Documentation. Medicare rules state that all patients receiving SNF care must have received inpatient hospital care for at least 3 consecutive days and be admitted to the SNF within 30 days following discharge from the hospital. Patients must receive SNF care for a condition for which they received treatment in the hospital. At a minimum, providers should obtain the following documentation related to each patient’s qualifying hospital stay:

Patient history and physical.

All laboratory reports and tests.

All physician orders and progress notes.

All inpatient therapy progress notes.

Patient discharge summary. 

Providers should obtain this information from the discharging hospital as soon as possible after a new patient is admitted to the SNF. Incomplete or insufficient records (especially those that establish a baseline level of patient function) will give contractors ample bases on which to deny your claim.

Therapy Documentation. All therapy care must be provided under a plan of care established by a physician, nurse practitioner, or licensed therapist. The documentation must also reflect the patient’s diagnosis, anticipated therapy goals, and the type, amount, frequency, and duration of therapy. The documentation should also include the patient’s prior functional ability, rehabilitation potential, and evidence of an expectation for material progress. At a minimum, the therapy documentation for each claim should consist of:

A treatment plan for each RUG code billed and for all dates of service on the claim.

A log of all therapy minutes that were provided during the dates of service on the claim.

Progress notes to support the look-back period for each RUG code billed as well as the entire payment period for the dates of service. 

Providers should ensure that information from the therapy logs (especially the number of minutes of therapy) accurately reflects the amount of therapy provided and is consistent with the information coded on the MDS. Inconsistent coding will likely result in a denial of the claim, despite the fact that these therapy services were properly provided.

Nursing Documentation. Under applicable regulations, patients must require skilled care on a daily basis in order to be eligible for post-hospital SNF services. Generally speaking, skilled nursing care is that which is so complex that it can only be safely and effectively performed by professional or technical personnel. Generally, examples of skilled nursing cited by SNF have often included:

Management and evaluation of the care plan;

Observation and assessment of the patient’s changing condition; or

Patient education services.

SNFs have sought to demonstrate a skilled level of nursing care by documenting the nurse’s ongoing observation and assessment of a patient’s condition. However, in order for observation and assessment to qualify as skilled care, the patient’s condition must such that imminent deterioration is possible. In those cases, observation and assessment of the patient only constitutes skilled care until the patient’s condition is stabilized. Providers should therefore document any and all facts and circumstances which indicate a possible imminent decline in the patient’s condition. Otherwise, a ZPIC deny the claim on the basis that the care given does not constitute skilled nursing care.

II.  Recommendations for Responding to SNF Medicare Audits: 

Over the past year, the number of SNF Medicare audits initiated by ZPICs has significantly increased, due in large part to the government’s continuing concern that the services being provided do not qualify for coverage and payment.

While SNF Medicare audits of your facilities may be inevitable, you can reduce the likelihood of an overpayment through the use of an effective Compliance Plan which includes the use of periodic self-audits designed to identify possible deficiencies which may exist.  Once identified, SNFs must immediately take remedial steps to correct any deficiencies which are identified and modify its practices (and the risk areas within its Compliance Plan) to better ensure that these problems do not reoccur.

Prior to conducting a review, we recommend that you contact your legal counsel to discuss possible review options.  Working with legal counsel, SNFs should consider working with outside third-party reviewers who are familiar with both ZPIC / PSC / RAC concerns and SNF coverage and payment requirements. While it is certainly important for providers to actively participate in the self-audit, a third-party engaged to direct the review may be more objective in their assessments of the documentation than the therapy or skilled nursing providers themselves. Attorneys who are familiar with the risk areas unique to SNFs can also readily identify problems with documentation, recommend strategies for improvement, and work with SNFs to adjust their Compliance Plans accordingly.  Ultimately, the assistance of knowledgeable counsel could help providers avoid (or reduce) future liability it audited by a Medicare contractor.  As a final point, regardless of whether a self-audit is conducted by a third-party or by the SNF itself, it is essential to keep in mind that:

 “If it doesn’t belong to you, give it back” – All providers, including SNF must comply with this simple rule.  Should you identify a Medicare or Medicaid overpayment, it must be returned to the government within 60 days.

 “Documentation of services rendered must be accurate” – Therapy and skilled nursing services must be accurately documented in each patient’s medical records.  It isn’t sufficient to merely state that therapy or skilled nursing services were provided.  As detailed above, SNFs must document aspects of the therapy or services provided which qualify as “skilled” care.  Finally, documentation must accurately describe the work actually conducted and ensure that the duration of services documented is correct.

Robert W. Liles, J.D., is a healthcare attorney who is experienced representing SNF and other health care providers in connection with ZPIC audits and / or reviews by other Medicare contractors.  Should you have questions, please give Robert a call for a complimentary initial discussion of your project or case.  He can be reached at:  1 (800) 475-1906.