Recovery Audit Contractors

chaotick · Mar 6, 2008

I've had to deal with this one at my facility... There were a fair number of grace days being requested by therapy (a contracted outfit) - which didn't make a lot of difference to my workload either way - and it mostly to make up for late in the week admissions... The owner got freaked and yelled at me for being too cordial/catering to therapy and was deathly afraid of triggering audits. And she also implied that the higher RUG levels meant a bigger slice of the pie for the therapy company and smaller slice for nursing/etc. (Beats me...) and (I like this one...) that all of the excessive therapy was causing the short term rehab people to leave early because they were all tired out from too much therapy... (most of the time they really didn't LIKE being in a stinky old nursing home and just wanted to be home in their own beds as quickly as possible...)

Now we're about to undergo a big 'culture shift' - the owner decided to hire 'in house' therapy people (March 1st) - and it seems that Grace Days are going to be just hunky dory 'cause a) everyone does it at least sometimes, b) not doing it at all ALSO can trigger an audit (what are they trying to hide?) and c) probably not necessary if the admit has had IV/transfusions in the hospital (it came to light recently that owner had also thought that people who'd had IV/transfusions had to not be in therapy to get the "L" or "X" level category... but then someone clarified and that became obsolete about 2 years ago... Beats me - I had no idea what MDS stood for a little more than a year ago... and I was trained (more or less - mostly less) by the old retiring MDS person who didn't feel comfortable with computers and didn't seem to keep up with changes in the law). The only reason I got the job was because the DON put her foot down and refused to take on MDS's on top of the other 1 million things she does every day (I love her to death - but she is NOT a detail oriented person in the way one needs to be to be good at MDS).

Nascar nurse, ASN, RN · Mar 6, 2008

This is from my Medicare MDS coordinator who has read some replies relating to grace days.
To those of you who wrote in about ALWAYS using grace day for PPS and never having a problem. Have you heard of RAC (Recovery Audit Contractors)? Florida, New York and California are pilot states. It is an audit done to recover over-paid Medicare dollars. It will be in every state by October of 2009. They closely monitor inappropriate use of Medicare rules and recoop money paid out.
For example, a facility in California was audited and had to repay $3.3 million, yes, million, and the reason. Most of it was due to over billing for unnecessary therapy and use of grace days to accomplish high RUG scores. They found that 95% of the therapy reviewed was unnecessary and they determined this by taking a month of Medicare billing, multiplied it by the number of hours claimed by therapy then counted the number of working therapist. The results were that it was virtually impossiple to provide all the therapy needed to reach RVB, RVC, RUC and RUB level RUG scores as there was not enough therapy staff.
Also, grace days are for the resident, i.e. out to the doctor, dialysis, not feeling well, etc, not to get more dollars for therapy. I hope that the MDS coordinator is choosing the ARD date and not the therapist, especially if your facility has contracted therapy.
If you have been allowing therapist to choose ARD date, try doing a profit/loss analysis for a month and you will be shocked to see how much your facility actually lost as well the patients that actually NEEDED a more intense level of therapy.

This is very interesting and not really suprising.

I am one of those that stated I routinely use grace days and have never had problem with it (and I haven't). The philosophy in my coorporation is that is the way to do things...got to maxamize those profits as much as possible... and subtley stated that if I want the job, that's how it will be.

Again tho, this organization you speak of does not surprise me and in the end will probably be a good thing (maybe there will be some medicare dollars left around when I get old). But, til then the RUX's rule.:bowingpur

Rexie68 · Mar 6, 2008

and in oct '09 mds 3.0 might be in use, right?? i'll worry about it if/when it happens, 'cause i just don't have time to think about it right now!! keep those rux's coming!!! (thank you, acf for giving that iv pain med right before discharge, so i can count it on my 5 day/admission mds....) :bugeyes:

RN 4 Life · Mar 14, 2008

this is from my medicare mds coordinator who has read some replies relating to grace days.
to those of you who wrote in about always using grace day for pps and never having a problem. have you heard of rac (recovery audit contractors)? florida, new york and california are pilot states. it is an audit done to recover over-paid medicare dollars. it will be in every state by october of 2009. they closely monitor inappropriate use of medicare rules and recoop money paid out.
for example, a facility in california was audited and had to repay $3.3 million, yes, million, and the reason. most of it was due to over billing for unnecessary therapy and use of grace days to accomplish high rug scores. they found that 95% of the therapy reviewed was unnecessary and they determined this by taking a month of medicare billing, multiplied it by the number of hours claimed by therapy then counted the number of working therapist. the results were that it was virtually impossiple to provide all the therapy needed to reach rvb, rvc, ruc and rub level rug scores as there was not enough therapy staff.
also, grace days are for the resident, i.e. out to the doctor, dialysis, not feeling well, etc, not to get more dollars for therapy. i hope that the mds coordinator is choosing the ard date and not the therapist, especially if your facility has contracted therapy.
if you have been allowing therapist to choose ard date, try doing a profit/loss analysis for a month and you will be shocked to see how much your facility actually lost as well the patients that actually needed a more intense level of therapy.
good luck.

below is an excerpt from the federal register detailing the appropriateness of grace days. ultimately it is appropriate to use grace days to more accurately capture therapy minutes or other treatments. it is not illegal to use day 8 to capture an ultra high rug category, in fact, as stated below it is another reason grace days were made available. please see below specifically the identified areas in red for more detail.

http://vlex.com/vid/23327224 link for: medicare: skilled nursing facilities; prospective payment system and consolidated billing.

g. mds scheduling requirements

1. grace days

comment: we received several comments asking about the appropriate use of the 3-day grace period provided for the medicare 5-day assessment. there is some confusion about when use of the grace days could result in the facility being at a high risk for an audit.

response: days six, seven, and eight, of the medicare covered stay, were provided as grace days for setting the assessment reference date for the medicare 5-day assessment. this assessment is to have an assessment reference date (mds 2.0 item a3a) of any day one through eight of the medicare part a stay. days one through five are optimal but days six through eight are also acceptable, and for some residents may actually be more appropriate; for example, to allow maximum flexibility for nurses to determine when to set the assessment reference date for the beneficiary's mds, and thereby lessen the burden of the increased frequency of assessments that accompanied the pps. thus, the resident can be assessed using any one of these first eight days as the assessment reference date for the medicare-required 5-day assessment.

however, we discourage the routine use of grace days for assessing every medicare admission. we plan to identify patterns of inappropriate use as we gain a better understanding of what facilities' practice patterns are. when a facility routinely uses a grace day as the assessment reference date for the 5-day assessment, it loses the cushion that these days provide against performing the mds later than day eight and, thus, risks being faced with payment at the default rate.

at this time our main interest is to encourage facilities to perform assessments timely and to recognize the grace days as a cushion and to use them as such, rather than as deadlines for setting each beneficiary's assessment reference date. the grace days are also provided to offset any incentive that facilities may have to initiate therapy services before the beneficiary is able to tolerate that level of activity.

our discussion in the interim final rule about the possibility of audits was intended to address the possible practice of routinely using grace days for medicare assessments. we were cognizant that the routine use of a grace day for the 5-day assessment would pose a temptation to back-date the assessment fraudulently when day eight was missed. we believed that any facility that routinely used grace days for the required assessments was liable to have assessments billed at the default rate; and that the absence of default rate billings in the facility's claims might indicate that some misrepresentation of the assessment reference dates had occurred.

unlike the routine use of grace days described above, we do expect that many beneficiaries who classify into the rehabilitation category will have 5-day assessment reference dates that fall on grace days. there are many cases in which the beneficiary is not physically able to begin therapy services until he or she has been in the facility for a few days. thus, for a beneficiary who does not begin receiving rehabilitation therapy until the fifth, sixth, or seventh day of his or her snf stay, the assessment reference date may be set for one of the grace days in order to capture an adequate number of days and minutes in section p of the current version of the mds to qualify the resident for classification into one of the rehabilitation therapy rug-iii groups.

another reason for the provision of three grace days for the 5-day assessment was to make it possible for beneficiaries to classify into the two highest rug-iii rehabilitation sub-categories. classification into the ultra high and very high rehabilitation sub-categories is not possible unless the beneficiary receives the sub-category's minimum level of services during the first seven days of the stay. we also intended to minimize the incentive to facilities to provide too high a level of rehabilitation therapy to newly admitted beneficiaries. having these extra few days allows time for those beneficiaries who need it, to stabilize from the acute care setting and be prepared for the beginning of rehabilitation in the snf. we expect facilities will not compromise any beneficiary's health by beginning rehabilitation therapy prematurely or at a level that is too rigorous for the individual's status. in summary, use of grace days is acceptable and permitted for patients with any condition. however, a facility that uses grace days routinely may be subject to audit to determine that assessment reference dates are accurately reflected.

nratchet · Mar 14, 2008

below is an excerpt from the federal register detailing the appropriateness of grace days. ultimately it is appropriate to use grace days to more accurately capture therapy minutes or other treatments. it is not illegal to use day 8 to capture an ultra high rug category, in fact, as stated below it is another reason grace days were made available. please see below specifically the identified areas in red for more detail.
http://vlex.com/vid/23327224 link for: medicare: skilled nursing facilities; prospective payment system and consolidated billing.
g. mds scheduling requirements
1. grace days
comment: we received several comments asking about the appropriate use of the 3-day grace period provided for the medicare 5-day assessment. there is some confusion about when use of the grace days could result in the facility being at a high risk for an audit.
response: days six, seven, and eight, of the medicare covered stay, were provided as grace days for setting the assessment reference date for the medicare 5-day assessment. this assessment is to have an assessment reference date (mds 2.0 item a3a) of any day one through eight of the medicare part a stay. days one through five are optimal but days six through eight are also acceptable, and for some residents may actually be more appropriate; for example, to allow maximum flexibility for nurses to determine when to set the assessment reference date for the beneficiary's mds, and thereby lessen the burden of the increased frequency of assessments that accompanied the pps. thus, the resident can be assessed using any one of these first eight days as the assessment reference date for the medicare-required 5-day assessment.
however, we discourage the routine use of grace days for assessing every medicare admission. we plan to identify patterns of inappropriate use as we gain a better understanding of what facilities' practice patterns are. when a facility routinely uses a grace day as the assessment reference date for the 5-day assessment, it loses the cushion that these days provide against performing the mds later than day eight and, thus, risks being faced with payment at the default rate.
at this time our main interest is to encourage facilities to perform assessments timely and to recognize the grace days as a cushion and to use them as such, rather than as deadlines for setting each beneficiary's assessment reference date. the grace days are also provided to offset any incentive that facilities may have to initiate therapy services before the beneficiary is able to tolerate that level of activity.
our discussion in the interim final rule about the possibility of audits was intended to address the possible practice of routinely using grace days for medicare assessments. we were cognizant that the routine use of a grace day for the 5-day assessment would pose a temptation to back-date the assessment fraudulently when day eight was missed. we believed that any facility that routinely used grace days for the required assessments was liable to have assessments billed at the default rate; and that the absence of default rate billings in the facility's claims might indicate that some misrepresentation of the assessment reference dates had occurred.
unlike the routine use of grace days described above, we do expect that many beneficiaries who classify into the rehabilitation category will have 5-day assessment reference dates that fall on grace days. there are many cases in which the beneficiary is not physically able to begin therapy services until he or she has been in the facility for a few days. thus, for a beneficiary who does not begin receiving rehabilitation therapy until the fifth, sixth, or seventh day of his or her snf stay, the assessment reference date may be set for one of the grace days in order to capture an adequate number of days and minutes in section p of the current version of the mds to qualify the resident for classification into one of the rehabilitation therapy rug-iii groups.
another reason for the provision of three grace days for the 5-day assessment was to make it possible for beneficiaries to classify into the two highest rug-iii rehabilitation sub-categories. classification into the ultra high and very high rehabilitation sub-categories is not possible unless the beneficiary receives the sub-category's minimum level of services during the first seven days of the stay. we also intended to minimize the incentive to facilities to provide too high a level of rehabilitation therapy to newly admitted beneficiaries. having these extra few days allows time for those beneficiaries who need it, to stabilize from the acute care setting and be prepared for the beginning of rehabilitation in the snf. we expect facilities will not compromise any beneficiary's health by beginning rehabilitation therapy prematurely or at a level that is too rigorous for the individual's status. in summary, use of grace days is acceptable and permitted for patients with any condition. however, a facility that uses grace days routinely may be subject to audit to determine that assessment reference dates are accurately reflected.

i understand what this is saying but, as it says in the area i highlighted in blue, the grace days are used for the patient and when he or she is unable to participate or tolerate therapy to acheive a high rug. nowhere in the above do i see something saying that the grace days can be used for therapists taking a day off.

RN 4 Life · Mar 14, 2008

i understand what this is saying but, as it says in the area i highlighted in blue, the grace days are used for the patient and when he or she is unable to participate or tolerate therapy to acheive a high rug. nowhere in the above do i see something saying that the grace days can be used for therapists taking a day off.

you are correct, it does not state that as a specific reason for there use, but i do believe the intent is to allow some flexibility to the patient and the staff. not making the rules so strict that someone should loose a rug category inadvertantly. as i am sure you are aware [but for new mds coordinators] grace days can also be used in the case where the mds coordinator is absent or ill [rai manual chapter 2 2-28], or to spread assessments out if too many fall on one day.

while they should be used sparingly, as stated in the rai manual, the use of grace days allows clinical flexibility in setting the ard and they can be used to more fully capture therapy minutes and other treatments.