How SNFs can steer clear of new crackdown on overbilling


Almost 25% of Medicare claims submitted by skilled nursing facilities (SNFs) in 2009 were wrong, asserts a recent report from the Office of Inspector General. As a result, the Centers for Medicare & Medicaid Services (CMS) will increase scrutiny on SNF billing.

The OIG analyzed SNF billings submitted in 2009. It concluded that $1.5 billion in inappropriate Medicare payments were made to those facilities for that year alone. Most resulted from upcoding, but a substantial percentage resulted from claims for ultrahigh therapy that the patient did not need, but for which there was a higher reimbursement rate. Some of the overpayment was attributable to misreported information into minimum data sets (MDS), which classify patients into resource utilization groups (RUGs) to determine how much Medicare pays SNFs.

What to do: CMS will follow up on the SNFs that billed in error and will increase scrutiny on all SNFs in the future. Based on this, SNFs should consider the following procedures to help steer clear of trouble:

• Expand review of claims before submission to Medicare to ensure accuracy of MDS items;

• Review and revise, if necessary, the method in which determinations are made as to how much and what type of therapy is administered to patients;

• Enhance fraud prevention systems to identify holes in the Medicare claim submission process; and

• Conduct unannounced internal audits of Medicare billing procedures and amounts.


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