The medical industry is trending toward greater utilization of skilled nursing facilities (SNFs) as an alternative to acute care treatment facilities while still offering the same quality of care. In addition, as the baby-boomer generation continues to age, greater utilization of SNFs will continue indefinitely. It is for this reason that health claim payers must look closely at skilled nursing facilities to contain rising health care costs. National Audit has created an audit program to ensure that health claim payers are not spending excess dollars in this area.
The Skilled Nursing Facility (SNF) audit program involves validation of the services provided by skill level or revenue code and the per-diem charge associated with that level/code.
A comprehensive review is performed that compares the bill submitted by the SNF, the SNF's contract with the client and the patient's medical record. The medical record is reviewed to ensure that the appropriate revenue code has been assigned based upon the services provided and the contract language and requirements. SNF's oftentimes inappropriately try to match the patient’s acuity level to the revenue code, resulting in billing errors.
Resource Utilization Group (RUG) SNF Audit
The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Consolidated billing also provides coverage for the physical, occupational and speech therapy services received during a non-covered stay. A RUG (Resource Utilization Group) score is determined by the completion of the Minimum Data Set (MDS) which calculates the RUG score. National Audit is prepared to conduct a comprehensive review of all claims where the costs are based on a RUG score. A detailed review of the complete medical record and associated MDS allows National Audit to determine if the billed RUG score is valid. In the event the review determines that an incorrect RUG score was billed, National Audit will report the valid score and report the reason the change was necessary.
