Medicare Audits-Assessments in the Lower 18

Medicare Audits-Assessments in the "Lower 18":  Harmony notes that the facilities that have patient days that feal into the "lower 18" RUG categories are at a risk of a Medicare Audit.  This sparks an interesting discussion about Medicare eligibility and the facilities responsibility to provide an entitled service.

It is important to emphasize that a patient's Medicare eligibility is not determined by what RUG group the patient falls into.  If a patient meets eligibility criteria, he/she is to remain "skilled" until that treatment regimen is essentially stabilized and the patient no longer demonstrates a need for skilled services.

It is also true that patients who fall into the "lower 18" are at an increased risk for detailed audit for Medicare eligibility.  As such, patients who are in these lower nursing care categories must have their skilled eligibility clearly documented to avoid payment denials.  Harmony would suggest that if a skilled patient is anticipated to fall into the "lower 18" groups that an in-house audit is preformed by the management staff.  The patients' skilled needs should be clearly outlined and communicated to the staff to ensure that supportive documentation is present in the medical record on a daily basis.  If no skilled needs are noted at that in-house review, and there is evidence that the patient's treatment regimen is essentially stabilized, the patient should be put on notice for denial of benefit.