Federal Agency Issues Report on Inappropriate SNF Therapy Billing
The Office of the Inspector General (OIG) in the federal Department of Health and Human Services released a new report indicating that $1.5 billion is inappropriately paid to nursing facilities under the Part A Medicare benefit. The report targets therapy reporting and utilization as the key problem area.
OIG report OEI-02-09-00200, Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than A Billion Dollars, was issued November 12, 2012.
“AOTA consistently provides information to members about how to ethically and accurately provide therapy. This report, however, shows that there are problems in the industry and that CMS [the Centers for Medicare & Medicaid services] will heighten its monitoring to find providers who are acting inappropriately,” said Christina A. Metzler, AOTA’s chief public affairs officer. “For therapists the message is clear: correctness in counting, providing, and documenting therapy is an important duty.”
The report focuses on several items, all of which are linked to therapy:
- Lack of consistency between minimum data set (MDS) information and the medical record; the report found that 47% of nursing facilities misreported data on the MDS.
- The majority of claims that were upcoded were put into the ultrahigh therapy category inappropriately.
- Other claims simply did not meet Medicare coverage criteria, including at least one case where there was no authorization from a physician.
- Therapy was provided in some cases despite the results of a therapy evaluation that indicated the patient was not in need of therapy.
- When claims had incorrect information it was most frequently in therapy.
The report was on claims filed in 2009; the OIG used independent evaluators to conduct the reviews.
In 2011, several changes were made to the skilled nursing facility (SNF) payment process, including changes that were targeted at therapy. One change was in how concurrent or group therapy was counted, and another was the requirement of a Change of Therapy (COT) Other Medicare Required Assessment (OMRA). CMS, in its response letter to the OIG, indicated that the COT OMRA is being used and that savings are likely as a result. The COT OMRA requires changing the payment for a patient whenever his or her therapy utilization changes. (See AOTA’s explanation of these changes from 2011.)
“We have seen changes over the past several years but CMS seems to be saying there will be more changes,” warned Fred Somers, AOTA executive director. “For instance, just as in Part B, CMS is investigating new ways of paying for therapy that can improve utilization control and accuracy.” The report indicates that CMS is considering payment alternatives for SNFs that would better link utilization to patient characteristics as well as methods to adjust payments after medical record reviews to reduce incentives to provide more therapy.
“Therapists must reinforce that their clinical judgment will determine decisions on therapy needed by SNF patients and should not be pressured to provide more or less than what can benefit a patient. Therapy provided must be specific to the individual patient’s needs (type, frequency, and duration) based on current, relevant assessments and therapist evaluations. AOTA provides practice guidelines, books, and continuing education products on these matters to help therapists provide appropriate, ethical practice that is in compliance with Medicare regulations,” said Deborah Yarett Slater, MS, OT/L, FAOTA, staff liaison to AOTA’s Ethics Commission.
CMS also indicated that they are sending the OIG report to all of their contractors, with instructions to watch for the types of problems raised in the report as they conduct medical review activities. CMS is also launching new efforts to assure that quality care is provided in SNFs. See the Capitol Briefing article, “QAPI Is Coming to Nursing Homes: Occupational Therapy’s Role,” in the November 12, 2012, issue of OT Practice for more information.
“Occupational therapy intervention, documentation, coding, and billing should accurately reflect the patient’s clinical status to withstand scrutiny by payers and align with our professional, ethical standards. It must clearly demonstrate the therapist’s clinical judgment and decision making process to support the need for skilled Medicare services and reimbursement,” said Slater. “AOTA has the tools to keep clinicians’ knowledge and skills up to date to ensure ethical and appropriate practice that brings the benefits of skilled occupational therapy to those who need and require it.”
Occupational Therapy Code of Ethics and Ethics Standards (2010)
Enforcement Procedures for the Occupational Therapy Code of Ethics and Ethics Standards
The American Occupational Therapy Association Advisory Opinion for the Ethics Commission: Ethical Issues Around Payment for Services