The Office of the Inspector General has discovered that some nursing homes are charging Medicare more then they should for resource utilization groups, and they want to put a stop to it.
In a study based on a sample group of Medicare bills submitted by skilled nursing facilities between 2006 and 2008, the OIG found that those facilities billed Medicare for higher paying RUGs even when the conditions of beneficiaries remained largely unchanged.
Skilled nursing facilities categorize beneficiaries into RUGs based on their care and resource needs.
Medicare generally pays the most for ultra-high therapy RUGs and pays more for RUGs for beneficiaries who require more assistance with certain activities of daily living, such as eating.
The OIG found, specifically, large increases in RUGs for ultra-high therapy. Payments to SNFs for ultra-high therapy increased by nearly 90 percent from 2006 to 2008, rising from $5.7 billion to $10.7 billion, according to the OIG. In addition, RUGs for high levels of assistance with daily activities increased.
The OIG found that for-profit skilled nursing facilities were far more likely than non-profit or government facilities to bill for higher paying RUGs, and a number of those facilities exhibited
"questionable billing" practices in 2008."Taken together, these findings raise concerns about the potentially inappropriate use of higher paying RUGs, particularly those for ultra-high therapy," the OIG said.
OIG officials are calling for the Centers for Medicare & Medicaid Services to monitor overall payments to skilled nursing facilities and to adjust rates if necessary. They're also asking CMS to change the current method for determining how much therapy is needed to ensure appropriate payments. CMS should also improve their monitoring of skilled nursing facilities that are billing for higher paying RUGs and follow up on facilities identified as having questionable billing practices, the OIG said.
CMS officials agreed with all of the recommendations except the recommendation to change the current method for determining how much therapy is needed for a patient. CMS officials said they are committed to pursuing additional improvements to the payment system.