Aligning Therapy & Documentation In Skilled Nursing Facility

For years, I’ve been hearing dedicated SNF Owners and Operators around the country say things like “The business is getting harder and harder,” or “I’ve never seen things quite like this.” Well, that sure is right. None of us have seen things quite like this.

Many around the country are energized and excited about new initiatives to improve quality and efficiency, return more patients safely to the community, and implement new and exciting treatments to medically complex patients in the SNF setting. Yet, according to the FY 2016 OIG Work plan, the OIG is ready to hammer down on the delivery of SNF therapy in the upcoming year. I understand that the information derived from the PEPPER report shows a startling increase in high intensity therapy in the past 3 years, up almost 9 percent. Don’t we need to consider the fact that SNFs are taking a more medically complex patient population than ever before? Aren’t shorter acute care stays also a factor in the need for more therapy for improved outcomes?

While bundled payment projects like Bundled Payments for Care Improvement (BPCI) Initiative seem to have us heading to a DRG-like quality based reimbursement system that so many of us are ready for, it begs this question in the mean time: “How do we expect patients to get better without clinically appropriate therapy?”

If the OIG wants to review the amount of therapy, I say “go ahead.” Now let’s make sure we are prepared. Let’s review the basics:

• Patients need therapy in order to improve, achieve functional goals, and achieve their highest state of well being.
• Skilled nursing needs to anchor the care of the patient and depict why he or she need the skills, knowledge & judgment of a nurse on a daily basis.
• Therapy documentation needs to be free of duplication of goals and show clear and measurable progress toward those functional goals.

Now, the July 16, 2015 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Proposed Rule is asking for more. As of 2013, SNFs were required to have a multi-step compliance plan in place with a non-retaliatory policy. Now it is suggested that “In addition to the auditing and monitoring systems described in proposed § 483.85(c), we also considered requiring periodic external audits specifically focusing on financial records and quality of care issues.”

External SNF Audit? By Whom?

Is having the right level of external audit the way to protect you and your Medicare program? Can having a trained clinician experienced in SNF care come to your building to review medical records and educate your team satisfy this requirement? Are external reviews of MDS and UB-04 claims just an exercise, or can they yield an untapped ROI? Can having this person work with your compliance officer show the OIG that you are serious about compliance in the event of a disaster?

While “Putting Two and Two Together,” these are some of the new questions to ponder.