The OIG’s 2008 Supplement Compliance Guidance focuses heavily on false claims, or claims for payment made to Federal health care programs for services which were not delivered or not delivered as claimed. One of the specific risk areas identified by the OIG as a potential false claim is the inaccurate reporting of resident case mix and, more specifically, improperly upcoding resident RUG category assignments. According to a 2006 OIG report, the OIG found that 22% of SNF RUG claims were upcoded.
The OIG recommends that both internal and external auditing of RUG assignments be a part of a facility’s compliance program and that these audits focus on resident assessments and care plans since those are linked directly to resident RUG classifications. Specifically, facilities should examine whether they are properly assessing, reporting and evaluating resident case mix (i.e., resident RUG assignments). As part of their compliance program, facilities should ensure that they employ an appropriate training program on the collection and use of case mix data for staff involved in the assessment, recording and assignment of resident status and case mix levels. Likewise, appropriate training should be in place for facility staff responsible for translating these levels of care data into bills submitted to third party payors including Medicaid, Medicare, TriStar and other Federal health care programs (as well as state Medicaid programs to the extent they are based on RUGS classifications).
Auditing and Monitoring for Proper Reporting of Case Mix
The following auditing and monitoring sample suggests one way facilities may approach the task of monitoring their reporting of case mix and ensuring compliance with the Federal requirement.