How to prepare for your next Medicare audit
Published: 2009-09-08 22:49:16
Author: Kenneth Kei Adams | McKnight's | August 10, 2009
Recovery Audit Contractors (RACs,) Medicare Audit Contractors (MACs,) Fiscal Intermediary (FI) prepayment and post-payment audits, and Office of the Inspector General (OIG) audits have been changing the face of post-acute care for many years. With potential changes coming in Medicare, there are important things that skilled nursing facilities need to do to prepare themselves. It is not just about prevailing through an audit—it is about improving patient care and improving outcomes.
Since 2004 there have been more than 145,000 fewer patients admitted to acute inpatient rehabilitation facilities (IRFs) to receive their post-acute care.i During that same time period, there were over 400,000 more Rehab RUG (Resource Utilization Group) assessments in skilled nursing facilities (SNFs).ii This is not just a switch from IRFs to SNFs; there are simply more patients receiving their rehab in SNFs. This has been a boon for those facilities geared to accept patients in need of physical, occupational and speech therapy services.
During the last decade, Medicare has begun to focus on pay-for-performance, value-based purchasing, clinical practice guidelines and evidence-based medicine.iii ivMedicare initially targeted hospitals and physicians and it is not unreasonable to expect that post-acute care providers are next. Several studies have suggested that therapy in SNFs does not produce the same outcomes than in IRFs.v vi In addition to the denials occurring for medical necessity reasons, MACs and FIs have begun to look at discharges to acute, patients that remain in therapy past 60 days, patients that discharge to hospice and patients that do not discharge home.
Many SNF providers have recognized the shift and are being proactive. Medicare is demanding that attention be paid to both outcomes and justification for providing therapy services. Nationally based corporations such as RehabCare, Five Star Quality Care, Fundamental and Nexion, as well as regionally based corporations such as Legend Healthcare, and smaller local providers, including Presbyterian Communities and Services and the Veranda at Preston Hollow, have begun to implement strategies to address both outcomes and justification for therapy as well as focusing on how to best appeal denied cases.
For smaller, local providers, mounting a full-scale legal battle to appeal denied cases can be both daunting and, in some cases, not fiscally permissible. In a situation where 10 cases are denied at an average of $200 per case, paying the Fiscal Intermediary back $2,000 is much less expensive than hiring a legal team. Larger organizations such as RehabCare and ManorCare have developed full legal departments. RehabCare's in-house team with a lawyer and multiple other staff members, has a current overturn rate of more than 90% (based on dollar amount overturned per dollar amount denied).
Full story
Published: 2009-09-08 22:49:16
Author: Kenneth Kei Adams | McKnight's | August 10, 2009
Recovery Audit Contractors (RACs,) Medicare Audit Contractors (MACs,) Fiscal Intermediary (FI) prepayment and post-payment audits, and Office of the Inspector General (OIG) audits have been changing the face of post-acute care for many years. With potential changes coming in Medicare, there are important things that skilled nursing facilities need to do to prepare themselves. It is not just about prevailing through an audit—it is about improving patient care and improving outcomes.
Since 2004 there have been more than 145,000 fewer patients admitted to acute inpatient rehabilitation facilities (IRFs) to receive their post-acute care.i During that same time period, there were over 400,000 more Rehab RUG (Resource Utilization Group) assessments in skilled nursing facilities (SNFs).ii This is not just a switch from IRFs to SNFs; there are simply more patients receiving their rehab in SNFs. This has been a boon for those facilities geared to accept patients in need of physical, occupational and speech therapy services.
During the last decade, Medicare has begun to focus on pay-for-performance, value-based purchasing, clinical practice guidelines and evidence-based medicine.iii ivMedicare initially targeted hospitals and physicians and it is not unreasonable to expect that post-acute care providers are next. Several studies have suggested that therapy in SNFs does not produce the same outcomes than in IRFs.v vi In addition to the denials occurring for medical necessity reasons, MACs and FIs have begun to look at discharges to acute, patients that remain in therapy past 60 days, patients that discharge to hospice and patients that do not discharge home.
Many SNF providers have recognized the shift and are being proactive. Medicare is demanding that attention be paid to both outcomes and justification for providing therapy services. Nationally based corporations such as RehabCare, Five Star Quality Care, Fundamental and Nexion, as well as regionally based corporations such as Legend Healthcare, and smaller local providers, including Presbyterian Communities and Services and the Veranda at Preston Hollow, have begun to implement strategies to address both outcomes and justification for therapy as well as focusing on how to best appeal denied cases.
For smaller, local providers, mounting a full-scale legal battle to appeal denied cases can be both daunting and, in some cases, not fiscally permissible. In a situation where 10 cases are denied at an average of $200 per case, paying the Fiscal Intermediary back $2,000 is much less expensive than hiring a legal team. Larger organizations such as RehabCare and ManorCare have developed full legal departments. RehabCare's in-house team with a lawyer and multiple other staff members, has a current overturn rate of more than 90% (based on dollar amount overturned per dollar amount denied).
Full story