The Office of Inspector General (OIG) released their findings of an audit they conducted to determine if hospital admissions of Indiana skilled nursing facility (SNF) residents who are enrolled in both Medicare and Medicaid (dually eligible beneficiaries) were potentially avoidable, and if level-of-care requirements for Medicare were met. Research by the Centers for Medicare & Medicaid Services (CMS) has found that many hospital admissions of dually eligible nursing home residents could have been avoided because the condition could have been prevented or treated outside of an inpatient hospital setting.
The OIG audit period was between October 1, 2016, and September 30, 2018. The audit covered 20,668 SNF claims with Medicare payments totaling almost $120 million, where each payment was greater than or equal to $350 for services provided during the audit period, to dually eligible beneficiaries in Indiana who had a preceding Medicaid-covered stay at the same SNF. They then selected and reviewed a stratified random sample of 100 SNF claims which totaled over $600,000.
The OIG found that posthospital SNF care provided to 98 of the 100 dually eligible beneficiaries, on whose behalf the sampled claims were submitted, was not associated with potentially avoidable hospitalizations. An independent medical review of the remaining two beneficiaries found that their conditions were potentially preventable and manageable at the nursing facility, but the nursing facility did not have effective prevention strategies. The beneficiaries in these two claims were hospitalized and later discharged to SNF care at the same facility.
Posthospital SNF care provided to the same 98 of the 100 beneficiaries met the Medicare SNF level-of-care requirements. The remaining two beneficiaries did not meet the Medicare SNF level-of-care requirements because the SNF physicians incorrectly determined that the beneficiaries required skilled nursing or skilled rehabilitation services, or both, on a daily basis.
The OIG noted in their review that for all 100 beneficiaries, physicians ordered SNF services. Records from the hospitals where 33 beneficiaries had a qualifying inpatient stay did not contain a clear and definitive hospital physician discharge order for SNF care. The hospital physicians mainly discharged beneficiaries “back to nursing facility” without specifying the level of care. The physician order not only affects the level-of-care determination, but also has a financial impact on the nursing facilities.
As a result of this review, the OIG did not have any recommendations, but stated that the quality of care in nursing facilities remains a concern. They will continue to monitor SNF claims, including those submitted on behalf of dually eligible beneficiaries, to determine whether services are appropriate and meet payment requirements.
Issue:
Upon admission, all residents must have a signed physician order that states the reason for skilled level of care. All skilled services provided should be reasonable and necessary for the specific person. Determination of skilled services should be individualized for each resident, and a trained professional should perform the evaluation to determine if the resident needs skilled services and meets requirements. Submitting claims to Medicare that do not qualify for skilled care can result in false claim allegations. Ensure that staff are aware that submitting a claim for unnecessary skilled services or upcoding for the purpose of financial gain can result in charges of false claims, fines, and other sanctions.
Discussion Points:
- Review your policies and procedures for determining if a skilled level of care is reasonable and necessary for each admission. Ensure that your policy includes requiring a signed physician order at the time of admission, stating the specific need for a skilled level of care when appropriate. Update as needed.
- Train staff on how to determine each resident’s level of care and if services provided are reasonable and necessary. Additionally, train admission department staff and nurses on requirements for a signed physician order stating why a skilled level of care is necessary for the resident at the time of admission. Document that these trainings occurred, and file each signed document in the employee’s education file.
- Periodically audit to ensure that skilled services provided to residents are reasonable and necessary. Additionally, audit to ensure that all residents upon admission to the facility have a signed physician order stating the need for skilled care when appropriate for the individual. To avoid a “reverse false claim” (i.e., an overpayment), make all reasonable efforts to determine if the skilled level of care is appropriate before submitting a claim to Medicare. If inappropriate billing occurred and any related overpayments exist, return the funds to Medicare within 60 days of identification.
