The coronavirus (COVID-19) pandemic presents skilled nursing facilities (SNFs) with formidable challenges on many fronts. In this time of great challenge and uncertainty, the last thing your facility needs is a negative COVID-19 audit finding, and the consequences that result from it.

As standard practice, the Centers for Medicare and Medicaid Services (CMS) utilizes Medicare Administrative Contractors (MACs) to perform initial SNF audits which gather data from minimum data sets (MDSs). From there, they analyze all MDS data to determine assessments that fall outside normal peer group ranges. Typical anomalies include an unusually high number of errors and abnormally higher or lower reimbursement rates, but CMS is thorough in its analysis, so any irregularity within your SNF’s operating scope could trigger a subsequent RAC audit—and potentially negative findings.

Today, SNFs across the U.S. are submitting a bevy of COVID-19 disaster relief-related claims to CMS for reimbursement. Given the severity of the pandemic and the large sums of money at stake, we at Richter believe CMS will examine 100% of all COVID-19 disaster relief claims; closely analyze them for errors; and when they occur, recoup the reimbursement originally allocated to your facility.

If your facility has made errors in processing COVID-19-related claims, you could be at substantial risk for negative audit findings—and potential recoupment of funds.

One of the most frequent errors we’ve seen through analysis of multiple SNF claims is skilling residents who do not meet skilled criteria. In these cases, SNFs classify residents for skilled care who perhaps just needed therapy because of decline in health status as a result of isolating in their rooms for lengthy periods of time. Typically, this rationale wouldn’t necessitate skilling under a Medicare Part A claim; rather, it would fall under Medicare Part B.

Reducing Risk for Negative COVID-19 CMS and RAC Audit Outcomes – Three Strategies

If you haven’t already, your SNF would be wise to adopt the following three strategies in an effort to prevent negative audit findings before they occur:

(1) Ensure proper criteria under CMS skillable areas. An ongoing challenge for many SNFs is knowing what to skill residents for under Medicare A, and what the skillable criteria are. Once a resident’s primary diagnosis has been established, the determination for skilling that resident falls under one or more of the five main skilled areas. While each resident must fall into at least one of these, up to five may apply as well. Moving forward, your clinical leadership and staff should familiarize themselves with the five reasons for skilling a resident and make absolutely sure that a given resident falls into at least one of these categories. The categories are:

1. Management and evaluation of a resident care plan seven days per week
2. Observation and assessment of resident’s condition seven days per week
3. Teaching and training activities seven days per week
4. Direct skilled nursing services to residents seven days per week
5. Direct skilled therapy services to residents five-to-seven days per week

Richter has developed an easy-to-use reference guide for each skillable area that includes the five area categories and criteria for determining resident applicability based on CMS directives. Download your free copy here.

(2) Provide accurate and specific physician certifications. Each physician certification must be very specific as to why the given resident is being skilled—and each must also give some indication why specific services are being rendered. For example, if your facility chooses to skill a resident in place due to a COVID-19 outbreak in your community rather than send them to the hospital, that’s a valid reason—but it must be clearly stated in the certification; it must account for actual activities relative to it; and the resident must still have a skilled need as well.

Note that section 1135 Medicaid waivers – specifically, waiver of the three-consecutive-midnights qualified hospital stay – provide SNFs with some wiggle room. But again, you must be very detailed in every part of the physician certification to help ensure your SNF complies with CMS requirements.

(3) Accurately code each resident MDS. One of the most frequent errors we’ve been seeing lately is the miscoding of isolation. Too often, SNF clinical staff click the isolation box for anyone who has been diagnosed with COVID-19; yet, these residents must be in private rooms for that to apply. One error like this leaves your facility open to recoupment of all reimbursement funds—or at the very least, a reduction in revenue if the facility is audited.

According to the CMS RAI manual v.1.17.1, coding for “single room isolation” is only possible when all of the following four criteria are met:

1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

Related article: Choosing a SNF Clinical Consultant – Five Competencies That Really Matter

Are You at Risk for Negative COVID-19 CMS and RAC Audit Findings? Our COVID-19 Disaster Relief Skilled Nursing Facility Audit Can Reveal the Answers

Given CMS’ laser focus on COVID-19 disaster relief-related claims, it’s imperative that SNFs of all sizes minimize their risk for audits and negative audit findings. While past mistakes can’t be corrected, Richter performs COVID-19 audits for SNF facilities throughout the country. We begin by analyzing a representative sample of claims, associated MDSs and physician certifications for a given time period to identify errors and issues. Based on our findings, we then provide a report with recommendations to leadership and staff, correct them and recommend/implement processes to help ensure that mistakes don’t occur in the future.

If you’d like to learn more about our COVID-19 Disaster Relief Skilled Nursing Facility Audit process and the approach we’d take for your facility, please call us at 866-806-0799 to schedule a no-cost, no-obligation discovery call.

To aid you in promoting infection prevention and control and other issues surrounding COVID-19, we have developed a COVID-19 Resource Center for skilled nursing facilities which will be regularly updated with the latest information.

Contact Richter’s Skilled Nursing Facility Consultants

Do you have questions about minimizing bad COVID-19 audit findings for your skilled nursing facility, or other LTPAC clinical challenges? Call Richter’s skilled nursing facility consultants at 866-806-0799 to schedule a free consultation.

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