Rodney Dangerfield was famous for saying “I get no respect”.  That saying should be the motto for the skilled services Certification/Re-certification requirements (you may know it as Cert/Re-cert).  With each audit I complete, I realize there is a significant lack of education and follow through regarding the skilled Certification/Re-certification process, not to mention - no respect.

Skilled Certification/Re-Certification Process

The Cert/Re-cert, which is tied to skilled service payment, is the only process that does not permit appeal.  If for no other reason, knowing that LTPAC providers cannot appeal a negative audit outcome for failing a particular element should ensure that those same providers educate their staff about completing that element.  This is the case with the Certification/Re-certification process – however, many audits fail for this element alone. A clearly defined policy and procedure regarding the completion of the Certification/Re-certification, not to mention a detailed follow-up practice is imperative to ensuring the accuracy of the process.

Continually I find this is not the case; staff is not ensuring each of the required elements are complete, including specificity.  It is not good enough to mark skilled for Physical Therapy (PT)/ Occupational Therapy (OT), you must specify what the person is being skilled for in PT or any other area.  Skilled nursing services for which the person qualifies should always be included.

Ensuring that supportive documentation exists for all skilled services is the key to a successfully completed Cert/Recert.  Additional requirements include:

• Estimated length of skilled services (generally listed as 30 days unless otherwise known)
• The discharge plan (i.e. home with Home Health)
• A statement identifying the skilled services are required by skilled staff during an inpatient stay

As if all of that is not enough, this information must be completed at specific intervals and it must be signed & dated by the attending physician at each specific interval. 

The Centers for Medicare and Medicaid Services (CMS) does not have a specific form for providers to utilize, but they are clear on the structure of the form that a LTPAC provider creates and utilizes, and they are very specific about the timelines for completion.  If the Cert/Re-cert facility chooses to slack on any of the required elements and the form turns into the cause of a negative audit outcome, there is no ability to appeal the denial/recoupment on this basis alone.  With that in mind, I call the Cert/Recert the “Golden Ticket” because without complete accuracy, payment can be revoked and not recovered through appeal channels. 

Someone asked me why they should worry about identifying nursing skilled services when there were therapy services being provided and clearly listed on the Cert/Re-cert.  Without hesitation, I was able to cite multiple audits where there was no Physician signed/dated Therapy Plan of Care, or others lacking clarification orders for the therapy services listed.  In cases such as these, the Cert/Re-cert would have had to include nursing skilled services along with the supportive documentation in place to avoid total repayment of all skilled services. 

The original “Golden Ticket” should be safeguarded after final review during the Triple Check process.  The original signed/dated Cert/Re-cert can be uploaded/scanned into many Electronic Health Records (EHRs) I prefer to give this precious copy to the finance department/ business office for inclusion in the financial file of the resident. These files are generally easier to locate, and with fewer persons handling them there is less chance to lose this irreplaceable and non-appealable skilled payment requirement. 

Providers should routinely audit the Certification/Re-certification forms for their skilled residents. At the very least, the forms should be reviewed as a part of the Triple Check process prior to submission of claims. Doing so, and correcting what you are able to, may make all the difference in the case of an Additional Development Request (ADR) or an audit.

With all of this in mind, it is hard to fathom that the Cert/Re-cert process “gets no respect” – if we do not understand the importance, we are liable to pay the consequence.

For questions regarding the Cert/Re-cert process, Contact Richter Healthcare Consultants at 866-806-0799.