Rehabilitation therapy in long term care facilities is under the microscope with Center for Medicare & Medicaid (CMS) and the Office of Inspector General (OIG). The OIG has penalized facilities for the actions of the vendor providing therapy. For example, Life Centers of America paid $145 million to settle a government lawsuit for allegedly submitting claims to Medicare for rehabilitation therapy services that were not reasonable, necessary or skilled. Skilled nursing facilities are being fined for improper therapist billing, over billing and other Medicare violations. Since the vendor providing rehabilitation care does not bill Medicare directly, the OIG turns to the facility for levying fines. For these reasons, it’s imperative that the facility administrator knows what to look for, how to provide oversight and what to do if something is wrong.
#1 Are therapists “hugging the RUG”? CMS is very interested in therapists who provide treatment that meets the category of the Resource Utilization Group (RUG). If therapists are providing exactly the number of minutes to meet the RUG – never over and never under – there is most likely a problem. The RUG categories are designed as a continuum, not categories. The administrator should ask for the minutes as reflected on the Minimum Data Set (MDS) Section O assessment and look for these things:
- Minutes do not reflect a total of 150 or 325 or 500 or 720. Minutes should reflect the actual minutes of therapy the resident needs to meet the goals.
- The minimum data set (MDS) should total varying minutes, such as 183, 416, 582 and even 806. If therapists are “hugging the rug” they do not treat between the RUG minutes.
#2 Concurrent or individual? Once a day, the administrator should walk through the therapy room, count the number of residents in the room participating in treatment, and the number of therapists. If there are an equal number of therapists to residents, it is likely the treatments are individual and are coded as individual minutes on Section O of the MDS. However, if there are more residents than therapists, those minutes must be counted as either “concurrent” or “group” on the MDS. Consult with the MDS coordinator to determine how the minutes are being reported on the MDS. One on one therapy is counted as individual minutes. One therapist to two residents is counted as 50 percent for each resident. A group is counted as four residents in a group. Be sure the minutes on the MDS reflect the actual amount of therapy provided. When the Payroll-Based Journal (PBJ) is in place, it is easier for CMS to determine if there are enough therapist hours to accommodate the number of minutes reported.
#3 Materiality. If a patient has a fractured hip, would he or she need to seek the services of a speech therapist? For a clostridium difficile (C-diff), would the services of a physical therapist be needed? Not necessarily so. Medicare Part A provides for covered services for patients who were in the hospital, and may receive covered care for “conditions for which they were hospitalized or for those that arose during a covered stay.” If a long-term resident has a history of cognitive decline for several years falls and fractures a hip, it does not give the speech pathologist the go ahead to treat for cognition decline. In this case the cognitive decline was not the reason for hospitalization, nor did it arise during a covered stay. When a speech pathologist, or any therapist, provides services that are not material to the reason for admission to the hospital, it merely increases the RUG, and consequently reimbursement. Conduct audits for materiality to confirm all treatments are associated with the covered stay.
#4 Part B therapy caseload should not increase when Part A caseloads decline. Some therapists decide that if the Part A census declines, they should “go find a Part B patient” to treat. Residents receive Part B therapy due to a decline in condition. If therapists are “scouting” for more patients to treat so they can carry a full caseload, it may be interpreted by Medicare as unnecessary treatment. Conduct therapy reviews to ascertain if in fact the resident receiving Part B therapy actually had a documented change in condition before the initiation of Part B therapy. Another consideration is length of stay: Do therapists end therapy on day 100 and avoid continuing treatment under Part B? No one is miraculously cured on day 100. Simply because Medicare Benefit days are exhausted is not an indication that the resident has reached the maximum recovery.
#5 Physician orders and plan of care are current. There is a regulation that requires the physician to approve the plan of care. If the therapist conducts an evaluation and submits it to the physician for signature, and the physician returns the plan of care in a timely fashion (translation – within 30 days), the facility is in compliance. However, if the physician does not return the signed plan of care in a reasonable time frame, the facility is out of compliance. To reduce the risk of non-compliance, require all therapists to write a telephone order in addition to the plan of care. The telephone order must contain: frequency, duration, modality and goal. By doing the telephone order, the physician has agreed to the treatment, even though the plan of care is not signed.