One-quarter of skilled nursing facility claims in 2009 contained errors, resulting in $1.5 billion in “inappropriate Medicare payments,” according to a November report from the Office of Inspector General.
Misreported MDS data constituted 47 percent of the error-ridden claims. Most misreported claims involved therapy levels, a primary factor in determining the RUG for reimbursement.
The study compared the electronic medical record to the Minimum Data Set (MDS) codes and their corresponding resource utilization groups (RUGs).
Recent actions taken against Medicare fraud are steps in the right direction, although more should be done to monitor claims, espceially those that involve high-end RUGs, the report noted.
The Medicare Payment Advisory Commission (MedPAC) reported to Congress its concerns that the therapy RUG system “encourages SNFs to furnish therapy, even when it is of little or no benefit.”
In September, the Center for Public integrity released its own study showing similar kinds of overbilling by physicians for Medicare services, especially through using the codes for high levels of care when lower levels of care were delivered.
As of 2012, skilled nursing is a $32.2 billion sector of U.S. healthcare.