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From Health Law Daily, March 10, 2016

Are SNFs sweeping patients into higher RUGs?

By Kathryn S. Beard, J.D.

Patients who need a significant amount of rehabilitation therapy may be receiving extra, unnecessary therapy minutes from skilled nursing facilities (SNFs), which have a financial incentive to bump patients into a higher resource utilization group (RUG), according to data released by CMS. The Skilled Nursing Facility Utilization and Payment Public Use File (SNF PUF), with data from SNF Part A institutional claims from calendar year 2013, includes information on over 15,000 SNFs, more than 2.5 million stays, and almost $27 billion in Medicare payments. The SNF PUF was created from CMS administrative claims data for Medicare beneficiaries enrolled in the fee-for-service (FFS) program, compiled by the CMS Chronic Condition Data Warehouse.

The SNF PUF contains information on utilization, payments, and submitted charges, and is organized by provider, state, and RUG. Individual SNFs are identified using their six-digit identification number. The SNF PUF includes the total number of stays and days provided, number of beneficiaries served, total and average Medicare payments, and total and average Medicare standardized payments for each SNF and RUG. There is no individually identifiable information about Medicare beneficiaries, and the data excludes any aggregated records derived from 10 or fewer beneficiaries to further protect individuals’ privacy.

CMS performed some analyses on the data and determined that the RUGs receiving the highest payments from Medicare are three “Ultra-High Rehab” groups followed by three “Very-High Rehab” groups. The six RUGs provide more total days of services than others, and receive a corresponding larger payment from Medicare than other RUGs. However, CMS noted Ultra-High and Very-High Rehab patients often were provided with an amount of therapy that is “very close” to the minimum amount of minutes needed to qualify for these categories, suggesting that if a patient is nearing that threshold, SNFs may provide extra therapy minutes to push the patients into a higher RUG. CMS is referring the issue to Recovery Auditor Contractors (RACs) for further investigation, to make sure that patients do not receive more therapy services than necessary.

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