Can a nurse get in trouble if....

explorereb96, ADN, BSN · Jun 25, 2016

Welllllll... technically a nurse is a provider...especially when it comes to Medicare and Medicaid billing. The pediatric subacute facility that I used to work for had signed onto the Medicaid system with our very own Medicaid provider number. In other words, it was "if it wasn't signed out, it wasn't done" X 2. Medicaid checked yearly for "holes" and paid accordingly. But you can't get "in trouble," unless you were grossly negligent and conspired with management to charge for services that were not authorized and/or not provided.

amoLucia · Jun 25, 2016

Economic rule for nursing homes - you don't get paid for EMPTY beds!!! So NHs do what they have to keep census up. The rules & regs that govern reimbursements from Medicare, Medicaid and insurances are mind-boggling. LTC has more regulations than even hospitals.

I believe that your facility is most likely working 100% within those regulatory guidelines. That star rating of 1/5 most likely reflects issues NOT related to its bed utilization status. If your place were fraudulent, you'd know about it FOR SURE!!!

My guess is that you're either a new nurse, or at minimum, very new to LTC. It takes a while to see 'the big picture' re all the little infinite governing R&Rs.

AutumnApple · Jun 25, 2016

I 'think' I understand what OP's concern actually is. It seems they believe the facility is admitting patients and putting them in a sub-acute bed and then following through with that by charging as if they were sub acute. Am I assessing where her fears are coming from properly?

Like someone else said, this is a coding/billing issue in truth.

To the OP: What you have to understand is, a bed is a bed. While the bed may be physically on the Sub-Acute unit, that does not mean it is only for sub-acute and nothing else. It's a guide, not a law.

If a medical patient is in a bed that is on the sub-acute unit, they would not charge as if it were sub acute simply because of the physical location of the bed. Medical facilities have to be more flexible than that for many reasons. Some examples from my hospital days:

1. One hospital I was at had a very small ortho unit. When they were full, ortho patients went to the M/s unit. Sometimes even when they weren't full it was just better staffing wise for a new pt to go to M/s.

2. Sometimes a patient who is near d/c would stay on the M/s unit rather than go to the rehab unit while they completed their physical rehab. program. Again, this was done because of staffing reasons usually. This pt was physically on the M/s unit, but was a rehab pt.

3. A pulmonary unit I was on had two rooms that were designated for vented patients. When there were vented patients on the unit, the nurses who took one of them in their assignment couldn't be charge nurse and had their pt load reduced by one. So this often meant placing new patients in the other rooms in such a way that made things work and nurses didn't have to travel a mile and a half between one pt and the next.

Room assignments are flexible, not concrete. And when someone is in a 'room' that usually is designated for something else..........the book keepers have to make sure it's billed right, not us.

Only way you could become responsible for it being billed wrong is if you were signing off on treatments and interventions that were not done or false. Don't do that..........and you're safe.

TheCommuter, BSN, RN · Jun 26, 2016

I'm a new nurse and I'm confused and I'm wondering, can they do that? Is this legal??

There's nothing illegal about about placing non-skilled (non-SNF) patients into beds on the SNF wing. If a patient has Medicare days available, an astute MDS coordinator or PPS coordinator can skill them for non-acute issues such as diabetes or hypertension under certain circumstances.

NOADLS · Jun 26, 2016

OP, are you really complaining about this?

You could potentially be receiving a patient of higher acuity and management gives you the nice surprise where you will instead receive a SNF patient.

The facility makes more money. You have a less stressful workload. Everyone wins.

I 'think' I understand what OP's concern actually is. It seems they believe the facility is admitting patients and putting them in a sub-acute bed and then following through with that by charging as if they were sub acute. Am I assessing where her fears are coming from properly?
Like someone else said, this is a coding/billing issue in truth.

Even if this was the case, if I were a floor nurse, why would I care? Not my problem.

Junebug903, LPN · Jun 26, 2016

Trach can also be LTC...depends on residents abilities and care plan.

lifelearningrn, BSN, RN · Jun 26, 2016

At a sub-acute SNF I worked at, they split the patients into 4 wings, two LTC, one sub-acute skilled, and one "rapid recovery". The LTC wings were always completely filled with residents, as was the skilled wing, which always had 19-26 patients, many with feeding tubes, traches, IV abx, etc. etc. The rapid recovery unit was almost always empty by comparison.. I think at most I ever say was 11 patients on that hallway. ALWAYS had more than half the beds empty. It used to annoy the hell out of me, because they, no matter what the census on each wing was, would have one nurse on each one. Of course, I was always by myself with the 19-24 skilled patients, while the nurse (with the most seniority) lazed about with her 6 rapid recovery patients (usually there for only for PT rehab, and needed little interventions on the NOC shift). It argued long and hard on deaf ears to split the labor of the two wings evenly-- but the DON said moving the meds from the skilled cart to rapid response cart was too much trouble. It was just easier to have one nurse on each hall, regardless of census on the hallway. Needless to say, I didn't remain in that facility for long.