In its 2008 Supplemental Compliance Guidance for Nursing Facilities, the OIG identities the issue of therapy services as an area of focus. According to the Supplemental Guidance, the following potential therapy practices raise compliance concerns for SNFs:
Improper utilization of therapy services to inflate the severity of RUG classifications to obtain additional reimbursement not warranted by the resident’s condition and medically-appropriate therapy needs;
Overutilization of therapy services billed on a fee-for-services basis under Medicare Part B consolidated billing. According to the OIG, this practice can place medically frail residents at risk of injury and may obscure a resident’s true condition;
Stinting on therapy services needed by residents and which are billed under Medicare Part A. This practice may lead to a decline in resident’s condition or failure to obtain their optimal functional status.
Each of these practices are potential false claims under the federal False Claims Act (see discussion in other risk areas on false claims in this compliance guidance).
To monitor compliance in the area of therapy services, and avoid these or other therapy compliance issues, the OIG recommends the following specific measures by facilities:
Facilities should develop policies and procedures to ensure that residents receive only medically-necessary and appropriate therapy services.
Facilities should ensure that therapy contractors and staff provide complete and contemporaneous documentation of each resident’s therapy services;
There should be regular and periodic reconciliation of physician orders relating to therapy services with care plans and other care orders, plans and documentation with the services actually provided;
Monitoring should include interviews with staff, residents and families to ensure the proper delivery of ordered therapy services; and
There should be ongoing assessments and re-assessments of the propriety of ongoing therapy services by the inter-disciplinary care planning team, which includes the physician responsible for a resident’s care.
Following is a sample auditing and monitoring approach facilities may wish to use, tailored to their own operations, to track and ensure compliance with therapy services requirements. As in other parts of this compliance guidance, we approach this monitoring task in three discrete sections, posed as questions to guide the compliance monitoring staff or team:
Specifically, what are we being asked to measure or monitor?
For each resident receiving therapy services, are those services needed and appropriate, as evidenced by adequate documentation of the need for therapy services and specifically what those services are and who is providing them?
Is the documentation of need for therapy services reflected properly in the resident’s care planning documents?
Is this information regularly reviewed by the care planning team and the resident’s physician to ensure the services remain appropriate for the resident?
Are therapy services ordered and provided based on need by the resident, without consideration of whether those services are paid for by Medicare Part A, Medicare Part B or some other payor source.
Do our bills for therapy services match the services actually provided and are those bills supported by complete, accurate and contemporaneous documentation of the need for therapy services and the provision of such services consistent with current medical orders?
Do we have in place facility policies and procedures reflecting the guidelines set forth in items 1 – 5, above?
Are existing therapy orders reconciled with current physician orders for therapy services?
Are we actually providing therapy services consistent with these orders?
Specifically, where should we look to answer questions 1 – 8, above?
- Periodically examine the facility’s policies and procedures governing therapy to ensure they are consistent with these principles. This will be done annually [or more often as appropriate] by [identify responsible staff].
- Monitor regular care planning meetings to ensure therapy services are reflected in the care plan as ordered, that documentation by therapy staff exists to support the orders and their proper delivery, and that the resident’s physician is involved in development and ongoing monitoring of those orders. This will occur monthly [or other appropriate frequency] and be coordinated by [identify staff person(s).
- Interview X number of facility staff, residents and family members to determine if they understand the need for ordered therapy services and whether, in their view, these services are being provided as ordered.
- Audit a sample of therapy billing records [define sample size] on the following schedule [monthly, quarterly or other] to ensure bills are supported by appropriate documentation of the need for, results of and delivery of ordered therapy services. This should include ensuring that the proper RUG category is reflected in light of the therapy serviced being provided and the documented need of a resident for those services.
- Audit a sample of physician orders and related therapy orders and care plans on a [define time frame] basis to ensure consistency. This should also ensure the documentation by therapy staff is complete, accurate and contemporaneous with the delivery of ordered therapy services. This will be handled by [define staff].
What do we do with the results of our therapy monitoring efforts?
- Results should be provided to the facility’s compliance officer and compliance committee for evaluation and response.
- Policies and procedures governing therapy services should be modified, as appropriate, based on these findings and appropriate training or re-training provided to relevant staff.
- Other corrective actions should be implemented as appropriate and explained to clinical and/or billing staff, with follow up to ensure compliance with same.
- This information should be provided to the Quality Assurance Committee and to the facility/company Board of Directors or owners, including the results of the audit, any problems identified and any corrective measures implemented, along with a plan for ongoing review and monitoring of corrective actions.: