Knowledge base

Long Term Care Fraud

Patients of LTACH’s are typically admitted from general acute care hospitals. These patients have specialized needs and often complex, serious medical conditions such as respiratory failure, neuromuscular disorders, traumatic brain and spinal cord injuries, stroke, cardiac disorders, non-healing wounds, renal disorders and cancer. As such, they benefit from being treated in a specialty hospital that is designed to meet their unique medical needs, and generally require a longer length of stay than typical in a general acute care hospital. In order to remain categorized as a LTACH, a long-term acute care hospital must have an average inpatient length of stay for Medicare patients (including both Medicare covered and non-covered days) of greater than 25 days. (Previous to October 1, 2002, average lengths of stay were measured with respect to all patients regardless of payor). LTACHs that fail to exceed an average length of stay of greater than 25 days for Medicare patients during any cost reporting period are paid under the general acute care hospital DRG-based reimbursement. In addition, LTACH’s are paid extra for certain pass through costs, which include bad debts, direct medical education, and blood clotting factors. Fraud applicable in this setting included DRG upcoding, admission or discharge manipulation in order to increase reimbursement, and manipulation of the 5/6 Rule. Are the long term care hospital (LTCH) (which are paid under PPS) appropriately handling early discharges to home and interrupted stays? Does the LTCH admit patients from sole acute-care hospital?

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