Most people think of nursing homes as providing long-term, end-of-life care, but many nursing facilities also provide short-term care, such as rehabilitative and therapy services, which is then reimbursed by the Centers for Medicare & Medicaid Services (CMS) under Medicare Part A. But CMS does not necessarily make Medicare reimbursements without any questions. In fact, the government will audit nursing facilities to make sure reimbursements are properly aligned with services rendered. And when the paperwork doesn’t exactly correspond with the payment, the government will seek to recover what it views as improper reimbursements.

Recovery auditors typically look for discrepancies in the nursing facility’s reimbursement requests. And while recovery audit decisions are generally appealable, it’s better to avoid an audit rather than necessitate an appeal. Fortunately, there are a few proactive steps to take prior to finalizing billing that may help avoid audits—or allow a facility to successfully weather closer scrutiny.

1. Compare MDS with therapy documentation. Generating billing information is a highly-involved process that includes not just a company’s billing department, but also its medical coders, MDS coordinators, therapy managers, and the nurses who complete the Minimum Data Sets (MDS). MDSs are used for nursing home resident assessment and care tracking, including documenting all types of therapy, such as speech, occupational, and physical therapies. To prevent an audit, it’s crucial to ensure all therapy units documented and logged match what is on the UB-04. This may sound simple in theory, but it’s a very complex process. For example, the MDS coordinator might have rushed through a data set without performing an internal check for discrepancies, such as a nurse who may have checked the wrong box. Alternately, there may have been a lack of communication among all the parties involved, or poor documentation prior to medical coders getting the information. It’s important to make sure care is documented on time and correctly, and that coding is correct, before finalizing and submitting a bill.
2. Verify RUG scores [AG1] and document services to withstand increased scrutiny. The general rule is that the higher the RUG score, the higher the reimbursement for the nursing facility. Due to the fact that higher reimbursements translate to more expenditures for the government, these types of reimbursement requests are generally scrutinized more closely. During the billing process for a patient with a high RUG score, it’s important to make sure the record addresses the issues that may impact the patient’s RUG level. When reviewing the record for such a patient, the reviewer should anticipate significant therapy for the patient, and perhaps additional entries for social services or other items deemed necessary for treatment. In other words, for high-level RUGs, the record should reflect a higher level of care. Documentation is the way to establish that the patient did, indeed, receive a greater number of care services.
3. Make sure forms are completely filled out and signed. One discrepancy auditors generally look for is whether all documents requiring signatures have indeed been properly signed. This is especially true for therapy care plans. Therapy is usually done pursuant to a doctor’s certification or recertification, which specifies the number of sessions or amount of therapy that’s needed. Therapy certifications need to be signed prior to submission to CMS in order to qualify for Medicare Part A coverage. At times, however, doctors don’t fill out the therapy certification completely, or forget to sign it. This can result in CMS refusing to reimburse—or seeking to recover reimbursements—for any therapy sessions that took place prior to the date on which a doctor signed a certification or recertification.

Getting ready to submit documentation for billing and government reimbursements can be a painstaking process that requires a line-by-line review. It also requires knowing what types of potential issues or discrepancies an auditor might be looking for, including those listed above. Fortunately, there are services available that can triple-check billing records and make sure all documentation is in order. Click here for more information.