Updated on: November 29, -0001

Resist Gaming the System

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Original story posted on: April 20, 2016

The time has come for me to get a little philosophical. During the April 4 edition of Monitor Mondays, we learned that the Recovery Auditors (RAs) are going to increase the number of their skilled nursing home (SNF) billing audits because previous audits demonstrated an increasing number of patients with ultra-high therapy resource utilization groups (RUGs) who just happened to be right over the time limit to qualify for that higher payment.

On March 30, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report on inpatient hospice billing that included a lot of distressing findings about hospices billing for inpatient care for patients who had no need for inpatient care, billing for inpatient care that was not provided, and even billing and being paid for inpatient care for patients who actually needed it but never received it.

Last week I spoke at the American Case Management Association national meeting and asked the audience how many have been told by finance that they had too many observation patients. The majority of hands went up (it was clear their administrations had not heard about Hirsch’s Law). And on April 4, I reported about a physician advisor who is sensing pressure to inappropriately admit patients as inpatient in order to increase hospital revenue.

At the same time, we are all continuing to deal with the Recovery Auditor (RA) program. Now, I am no fan of the RAs. The high ALJ overturn rate on short-stay denials showed that they had no idea what they were doing at first, and the contingency fee structure set up perverse incentives, but how the heck can we proclaim the high ground when every week there is another report of providers stretching the rules to increase revenue? I know that “no margin means no mission,” but if we want more margin, we need to go the payers, commercial plans, and Medicare, and explain why we deserve more money for the proper care we are providing. What we don’t do is stretch or break the rules to get it.

Giving a SNF patient a few extra minutes of therapy that won’t benefit them to get into the next RUG and get more money is wrong. If hospice organizations feel that the standard daily rate is too low, they should not make up for that by billing inappropriately for patients in inpatient hospice; they need to demonstrate why they deserve a higher daily rate.

We can’t start admitting patients as inpatient solely because the payment for observation is too low. That is wrong. If we keep doing these things, we will viewed as no better than those we are criticizing.

And if that is how we are going to continue to behave, then we deserve every audit that CMS sends our way – even by the RAs.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

Contact the Author

RHirsch@accretivehealth.com 

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