SKILLED NURSING FACILITY REIMBURSEMENT FRAUD
For each of the RUGs, the Medicare SNF per diem payment is calculated as the sum of three parts: the nursing component, the therapy component, and the non-case mix component. Under the nursing and therapy components of the payment rate, each of the RUGs carries a uniquely assigned relative weight factor. This relative weight factor, or case mix index, represents a relative index or resource consumption. Resource-intensive patients are assigned to a RUG that carries a higher relative weight factor. This RUG-specific relative weight factor is multiplied by the applicable nursing and therapy base rates (which vary depending on whether the SNF is urban or rural) to develop the nursing and therapy components of the per diem payment rate. These two components are then added to the non-case mix adjusted component, resulting in the total PPS per diem payment rate.
For a SNF admission to be covered under Medicare and most other Government Healthcare Programs, the beneficiary must have a qualifying hospital stay (meaning an inpatient hospital stay), of not less than three consecutive days before the beneficiary is discharged from the hospital. The beneficiary must enter the SNF within 30 days after discharge from the hospital or within such time as it would be medically appropriate to begin an active course of treatment, where the individual’s condition is such that SNF care would not be medically appropriate within 30 days after discharge from a hospital. The skilled services must be for a medical condition that was either treated during the qualifying three day hospital stay, or started while the beneficiary was already receiving covered SNF care. Additionally, an individual shall be deemed not to have been discharged from a SNF, if within 30 days after discharge from a SNF, the individual is again admitted to the same or a different SNF.
Skilled Nursing Facility Fraud can take various forms. Qui tam lawsuits often arise from widespread and systematically upcoded RUG rates, and/or the provision of lack of medically necessary skilled nursing or therapy services.