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« When It's Smart to Take that "No-Pay" Referral | Main | Coming to Your Census: Step 3 of 8—Don’t sweep diminished Medicare reimbursement revenue under the RUGs »

01/25/2011

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As a former Medicaid/Mrdicare (Title IXX & XVIII)Auditor and CEO of 120 Bed For Profit SNF, I am surprised by the title of this report. I can say that the purpose of OIG reporting is to make the agency in charge of the reimbursement aware of the fact that they are doing a poor job of policing their clients. The tools used in this business are the regulations, the authoritative interpretations (42 CFR etc) and the process and methods used to reach the conclusions. It is often based on the standard auditing and investigation procedures laid out in the Audit Manuals. There is not much room for the Auditors' judgement or rationality of findings in the process. Whether a facility is processing the Care Given Data and information correctly or not is not the question but what that process leads to; in this case to billing, is in accordance to the law, rules and regulation is the question and this often than not becomes a major problem logistically as well as financially for the providers. I have not seen the report or the underlying data but it is not a good practice to pin the findings on entire industry for all the anomalies found. If indeed majority of the community is doing something in one way and that is against the rules, then rules need to be reviewed for the interpretation and practicality. If some SNF have fallen outside the set segment of curve (2 STD from the mean) then question should be asked if they did it within the reimbursement rules or outside of it. Auditors often use comparison as a starting point to see who is likely to be a candidate for investigations and sometimes they are right and most cases may find that some SNF use professionals to achieve financial goals and most depend on the in house staff and results vary dramatically. In the current systems of Prospective Payments, there is not much room to be creative to enhance reimbursements and if someone is cleaver enough to do so, that entity sticks out as a sour thumb in the desk audit analysis of similar facilities. One can stretch therapy times to meet the next level but that too has a limitations which most professional service providers have discovered. It will be interesting to read the report and do rebuttal analysis of findings and methods used to arrive at them.

Thanks for your comment. I find that the OIG consistently extrapolates findings to imply that the entire industry is behaving poorly based on data that doesn't support such broad characterizations. It is frustrating, because it ends up seeming punitive instead of constructive to SNFs. I have another post coming on just that topic.

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