Skilled Nursing Facilities (SNFs)
Audit and Compliance Issues
Effective Compliance Programs
Skilled Nursing Facilities (SNFs) are one of the most heavily regulated types of health care entities in the country. SNFs are required to meet strict Medicare Certificate of Participation (CoP) requirements and are also the target of frequent audits from various sources, including from RACs, MACs, ZPICs and private payors.
At Wachler & Associates, P.C. we have been counseling SNFs for the past 25 years on issues such as audit defense, billing compliance programs, HIPAA compliance and addressing complaint investigations. Because we frequently represent SNFs in audits, we understand the compliance issues that can be problematic for SNFs and can assist SNFs to develop an effective compliance program to address these issues.Overview
In order for a patient to qualify for SNF services, the patient must have had a prior three day qualifying hospital stay and the patient must be transferred to the SNF facility for treatment within 30 calendar days of that qualifying hospital stay.
In addition to the qualification prerequisites, the services must meet the Medicare definition of “skilled” services, which generally means that the services must be ordered by a physician and require the skills of technical or professional personnel. The SNF must be treating the beneficiary for a condition for which the beneficiary received treatment during the qualifying hospital stay, but this condition does not need to be the primary diagnosis upon hospital admission. The beneficiary must also require skilled services that can only be provided “as a practical matter” in an inpatient setting.
For Medicare to pay for SNF services, every beneficiary must have a certification from a medical professional. An attending physician, nurse practitioner, or clinical nurse specialist working in collaboration with the attending physician may sign the required certification.Audit and Compliance Issues
SNFs are frequently the target of audits from both federal payors (Medicare), through contractors like Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), and Zone Program Integrity Contractors (ZPIC), and private payors (Blue Cross, Aetna, etc.).
Our attorneys understand SNF billing and documentation issues and are experienced in defending these issues. Because we understand the issues which create audit risk, we can help SNFs to identify these issues and address them proactively.
Some of the focus areas that we have seen when defending SNFs in Medicare audits include:
- Whether the resident’s medical condition warrants the level of care being provided and billed. Specifically, whether the resident needed skilled services such as skilled nursing, physical therapy, occupational therapy, and speech/language therapy.
- Whether the appropriate Resource Utilization Group (“RUG”) score was billed.
- Whether the resident met the mandatory qualifying three day hospital stay and whether the resident was transferred to the SNF within 30 days of discharge from the hospital.
- Whether the hospital stay is actually a “qualifying” stay, i.e., whether the treatment being received in the SNF is for a condition that was being treated in the inpatient hospital setting.
- Whether SNF services for patients with primarily psychiatric diagnoses are appropriate (note that the Medicare manual states that a hospitalization in a psychiatric hospital is cannot be a qualifying stay, but is silent as to whether a psychiatric stay in a general hospital can be a qualifying stay).
For more information on our firm's audit defense experience and the Medicare appeals process, please see our audit website at RACattorneys.com.Effective Compliance Programs
Effective compliance programs are an essential tool for identifying and mitigating audit risks. Pursuant to healthcare reform changes, compliance programs have become a mandatory Condition of Participation (CoP). As discussed on our compliance page, our firm can assist with the implementation of an effective compliance program.Complaint Investigations
Investigations of complaints by state agencies can be a stressful time for nursing home administrators. Our attorneys are experienced at communicating with investigators, developing corrective action plans and appealing to the DAB as necessary.
For links to Medicare online manuals go to the website: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html
For a link to all of CMS's SNF materials, please see: http://www.cms.gov/Center/Provider-Type/Skilled-Nursing-Facility-Center.html
Our attorneys have written many articles regarding urgent care centers. For a list of Wachler & Associates articles, please click here .
The attorneys of Wachler & Associates often speak on issues relevant to urgent care centers. For a list of Wachler & Associates speaking engagements, please click here .