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  • Medicare Compliance

    Medicare Compliance

    When Rehabilitation Services are either partially or primarily qualifying the beneficiary for the skilled nursing stay, it is important to ensure that the provider of services has demonstrated through review of the medical record that ‘the furnished services and the intensity of these services as defined by the RUG group were reasonable and necessary for the beneficiaries condition’.

    In general the provider of services must demonstrate that the therapy services provided (Physical, Occupational or Speech Therapy) were specifically related to the treatment plan which was established based upon measurable and objective findings from the therapy initial evaluations. The therapy evaluations and plan of care must demonstrate that upon initiation of treatment there was an expectation that the patient’s condition would improve materially in a reasonable and generally predictable period of time. In addition, the provider of services must demonstrate that the services were supported by the therapy documentation and medical record and that the services provided met the criteria for skilled services as defined in 30.2.1 and 30.4.1.1.

    Theracore performs a variety of services related to Medicare Compliance designed to decrease the facility’s risk for Medicare denials. Typically all services begin with a detailed assessment of the facility’s documentation compliance. The facility’s clinical documentation is reviewed to specifically assess whether it appeared that the services were reasonable and necessary requiring the skills of nursing and/or a therapist; documentation supporting evaluations and re-evaluations, treatment plan of care, and progress notes; determination of appropriate ADL index and assignment of RUG classification and transfer of appropriate HIPPS Codes, ARD dates, units of service and diagnosis codes to the UB-04.

    Areas of non-compliance are identified and an action plan detailing recommendations deemed necessary to achieve compliance is designed. Theracore provides a variety of services and trainings that are facility specific and aimed at correcting deficiencies. Repeated auditing of clinical documentation and facility processes to ensure that compliance is maintained may also be recommended.