CMS Reviews SNF Utilization Data for Therapy Trends
The new data set released by Centers for Medicare & Medicaid Services (CMS), the Skilled Nursing Facility (SNF) Utilization and Payment Public Use File (PUF) or SNF transparency data, details information on services provided to Medicare beneficiaries by SNFs. The new data includes information on 15,055 SNFs, over 2.5 million stays, and almost $27B in Medicare payments for 2013. The data is posted on the CMS website.
The data set identifies services provided by SNFs grouped according to Resource Utilization Groups (RUGs). For each SNF and RUG, the data set has the total number of stays and days provided, number of beneficiaries served, the SNF’s total and average charges, the total and average allowed amounts, the total and average Medicare payments, and the total and average Medicare standardized payments. The data set does not contain any individually identifiable information about Medicare beneficiaries. To further protect the privacy of Medicare beneficiaries, any aggregated records which are derived from ten or fewer beneficiaries are excluded from the SNF PUF.
The SNF PUF data allows many types of analyses to be performed, including summary analyses by RUG, as demonstrated in the CMS Transparency Data Fact Sheet. The RUG with the highest total Medicare payment at $7.77B was RUB (Ultra-High Rehab – ADL 6-10). The data also allows for the review of therapy minutes delivered per RUG. CMS is reviewing the amount of beneficiaries per facility that received therapy minutes within ten minutes of the threshold for the RUG score.
This is a gray area as far as reimbursement, since the resident did recieve a sufficient amount of minutes to achieve the category, but patterns of this type of utilization can represent treating to the RUG score, rather than achieving a RUG score by treating the resident. According to CMS, the program was designed to capture the amount of therapy a resident receives based on an individualized treatment plan. It was not designed to use the RUG score to design the treatment plan. CMS has requested Recovery Audit Contractors (RACs) to look further into these patterns of utilization.
Providers can review the therapy minutes aggregate data available to determine if they are an outlier facility with particularly high percentages of therapy minute delivery patterns within ten minutes of the RUG thresholds. It is anticipated that facilities demonstrating these utilization patterns may be chosen for review. Facilities should ensure that resident treatment plans are individualized based on resident need and that therapy minute delivery is treatment and goal based, rather than choosing a RUG category to aim for.
Contact: Michelle Synakowski, msynakowski@leadingageny.org, 518-867-8850.