Quiz: Medicare Part A for SNF Therapy Professionals-Criteria Criteria, Reimbursement and Fraud Triggers

Medicare Part A coverage in the SNF covers a resident’s expenses including room and board, therapy services and nursing services.

If a resident is “cut” from Medicare Part A before using all 100 days, they can “restart” Part A if done so within 30 days of the recent skilled episode.

The Medicare Benefit Policy Manuals contain all Medicare regulation. In what Chapter can the rules for Part A in the SNF be found?

Medicare Part A requires the following – Check all correct answers:

Medicare payment is based on providing SKILLED SERVICES…or services that require the SKILL of the NURSE or THERAPIST.

The following statements are True:

• Diagnosis or prognosis is NOT a factor in deciding if a service is SKILLED
• Potential for recovery is NOT a deciding factor
• The key is if the SKILL of the nurse or therapist was needed—if the service could have been provided by non-skilled personnel (aide, family) it is not skilled

In order to meet the coverage criteria for SNF Part A, skilled services need to be provided on a daily basis. For nursing services, daily is defined as 7 days per week. For therapy, daily is defined as 6 days per week.

Services provided by a skilled therapist or nurse are considered skilled, regardless of the activity that is provided.

The following are all categories of skilled care examples except:

The only way to prove skilled services are reasonable and necessary is through documentation.

Medicare Part A transitioned away from the RUG-IV reimbursement system to the Patient Driven Payment Model in October 2019 because:

By placing therapy days and minutes in Section O of the MDS, the therapist is attesting that those services, including the MODE of therapy, meet Medicare criteria and are skilled, reasonable and necessary and supported in the documentation.

PDPM practices will bring about new negative practice patterns that will eventually arise as False Claims Act lawsuits, just as the RUG system generated multiple False Claims Act lawsuits.  Examples of negative practice patterns in the RUG system included: Placing all residents in Ultra High, Achieving exactly 720 minutes in the lookback period for Ultra High, Having the Rehab Manager set the therapy schedule for all disciplines, etc.

What are PDPM potential negative practice patterns that may come into scrutiny with a chance for loss of Part A payment?

(Check all that apply)

When the Department of Justice and the Federal Government bring about a False Claims Act lawsuit for Medicare Part A, it is the SNF that is charged. SNF employees and contract staff cannot be included in the lawsuit.

Which of the following regarding skilled therapy are true? Check all that apply.