• OIG- Billing Practices in Skilled Nursing Facilities

    Thursday June 23, 2011

    A summary and suggestions regarding the Office of Inspector General's Report on billing practices in Skilled Nursing Facilities

    In December, 2010, the OIG issued a report on Medicare Part A services provided in the SNF setting. This summary addresses the findings along with suggestions. 

    In the recent past the OIG has found a number of issues with SNF billing for Part A services. One such report analyzing claims from 2006-2008, found that 26% of claims submitted were not supported by the medical records resulting in over $500 million in potential overpayments. Along with these findings, the Medicare Payment Advisory Commission indicated that SNFs may be improperly billing for therapy in order to obtain additional Medicare payments.


    • SNFs were increasingly billing for higher paying RUGs, even though the beneficiary characteristics remained almost the same.
    • For-profit SNFs were more likely to bill higher paying RUGs than nonprofit and government SNFs.
    • Some  SNFs had questionable billing in 2008, frequently billing for higher RUGs and having longer length of stays (LOS) than other SNFs.

    OIG Conclusions

    These findings raised concerns about the potentially inappropriate use of higher paying RUGs, especially the Ultra High category and deduced that the payment system offered incentives to place beneficiaries into these categories when that level of care was not needed. The report acknowledged that a new payment system was being introduced but felt that more needed to questionable billing practices.


    If you are not sure if you are up to date with the Medicare guidelines and documentation standards or whether your SNF would pass a RAC Audit or other OIG or CMS review, then consider looking for related regulations, guidelines, MDS analysis on LTC Provider University's website.

    Click here for a copy of the Full Report

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  • Reporting Reasonable Suspicion of a Crime in a Long-Term: Section 1150B of the Social Security Act

    Friday June 17, 2011

    Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility. Reports must be submitted to at least one law enforcement agency of jurisdiction and the state survey agency (in fulfillment of the statutory directive to report to the Secretary).

    This memorandum discusses applicability of this provision to the following Medicare and Medicaid participating long-term care provider types that are collectively referred to as "facilities" or "LTC facilities" in this memorandum:

    • Nursing facilities (NFs),
    • Skilled nursing facilities (SNFs),
    • Hospices that provide services in LTC facilities, and
    • Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).

    Click here for the report:

    June 17, 2011 Reporting Reasonable Suspicion of a Crime

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