Report: Nursing home therapy reimbursement under review as reform law toughens up

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Report: Nursing home therapy reimbursement under review as reform law toughens up
Report: Nursing home therapy reimbursement under review as reform law toughens up
Healthcare analysts at the Department of Health and Human Services are re-evaluating Medicare's “ultra-high” billing category for therapy services in skilled nursing facilities as a potential way to reduce wasteful spending, according to a Washington Post report.

Although the ultra-high billing category was itself originally designed to curb fraud and abuse in the Medicare program, alleged misuse quickly could have contributed to as much as $542 million in overpayments to skilled nursing facilities annually, federal investigators have said. The amount could be closer to $2 billion annually now, the Post report alleges.

Congress created the billing category in order to more accurately assess the costs of caring for skilled nursing patients. It intended for 5% of patients to fall into that category. Today, providers have placed an average of 9% of their patients in the ultra-high category nationally, with at least one nursing chain classifying up to 64% of its patients in it, according to the Post analysis.

"Facilities have been able to bill the way they want, and they are billing for more services than they are providing to people," said Toby S. Edelman, a senior attorney for the Washington watchdog group Center for Medicare Advocacy, in the Post article. "There's been a lot of abuse."

A 2006 inspection by HHS found that 26% of claims made in the ultra-high billing category were unsubstantiated by medical records. In addition, some of the claims were deemed a “waste of time” because patients were too sick to benefit from skilled nursing care, the Post reported. The ultra-high billing category is undergoing increased scrutiny with the recently signed healthcare reform law tightening regulation around it. In addition, regulators say billing groupings are slated to undergo further refinements over the coming year.