Steven Littlehale

In January, Rehab Care, a large therapy company, settled a $125 million whistleblower lawsuit with the federal government for allegedly placing patients in the highest therapy reimbursement groups improperly.

Not only did the company settle, but the skilled nursing facilities involved also reached million-dollar settlements with the U.S. Department of Justice.

This event, like many others, reminds us of the increased scrutiny that delivering therapy at Ultra High (RU) levels can bring to Medicare providers. The 2016 OIG work plan calls for increased scrutiny on the RU category because therapy delivery has increased over time, despite resident characteristics not having changed.

In 2014, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) found that 55% of total days were billed at an RU category.  Similarly, PointRight research identified 53% of the Medicare Resource Utilization Groups (RUGs) that were billed in 2015 landed in an RU category. Despite increased scrutiny, providers continue to deliver and bill at Ultra High intensity for the majority of Medicare days billed.

Do you know how your center stacks up against others in delivering RU levels of therapy compared to others at a state or national level?  Are you an outlier? If you don’t know, go to to access your PEPPER report. This is updated annually on or about April 18. If the percentage of residents in Ultra High RUG is significantly different from your peers, you are at higher risk for an audit. Being different doesn’t mean you are doing something wrong, but it does mean you might garner additional (and unwanted) attention.

So what is the answer? Follow these four steps:

1. Build simple checks into compliance programs to ensure reasonable and necessary services are provided at an individualized level of intensity.

2. Review policies and procedures that address how the RUG levels are set upon admission.

3. Document the clinical factors used to set the RUG level.

4. Document the beneficiary’s response to, and benefits from, treatment supporting the need for the intensity provided.

Nursing staff’s Medicare documentation should support the need for inpatient rehabilitation and record the resident’s response to the therapy program.

Grab a chart (or two) and take a read. The contents in the medical record (electronic or otherwise) tell the story and the details matter. When doing audits, do you see documentation describing the benefits the resident received from therapy? Statements explaining what the resident required and received from skilled therapists and nurses should support your claim. Without this piece, it’s difficult to understand the clinical judgment behind decisions related to individual treatment plans, and it’s even more difficult to defend your claim.

Ultra High therapy services are appropriate for many Medicare beneficiaries! Measurement of key outcomes like improvement in function, average length of stay, discharge to community rates and rehospitalization may help explain your high RUG utilization; however, in today’s traditional Medicare environment, these are not the metrics used to identify potential fraud and abuse. Claim reviews start and end with the bill, the MDS, and your team’s documentation. Take these simple steps to help ensure your team is ready and documentation is available should increased scrutiny come your way.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.