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A sharp increase in the number of SNF Part A Post-Pay ADRs (Additional Documentation Requests) was noted in late December for claims with 2015 dates of service. The new medical review activity is being conducted by Strategic Health Solutions, CMS’ Supplemental Medical Review Contractor with responsibility for determining payment accuracy of SNF Medicare Part A Therapy Services.

OIG Study Prompting COT OMRA Target
The Office of Inspector General (OIG) conducted a study of how SNFs utilized three new MDS PPS assessments (Start of Therapy, End of Therapy and Change of Therapy Other Medicare Required Assessments-OMRAs) initially implemented by CMS in FY2011 and FY2012 with the goal of better reflecting the amount of therapy actually being provided throughout the skilled stay. The assessments were intended to provide a better picture as to when beneficiaries start therapy, end therapy, and decrease or increase therapy significantly enough to impact the RUG payment; however, the study found that the new assessments only changed billing in therapy slightly, suggesting that some SNFs may be using them incorrectly potentially resulting in improper payments. Additionally, SNFs used assessments differently when decreasing therapy than when increasing therapy. These suspected errors cost Medicare an estimated $143 million in payments for FY2012 and FY2013, prompting the current review activity project Y4P0432.

Providers are considered as having high outliers for the COT OMRA target area on FY2015 SNF PEPPER when triggering above the 80th percentile compared to peers. The national 80th percentile for FY2015 COT OMRA use was 17.8%. Retrieve your facility SNF PEPPER data here to determine your COT OMRA rate compared to peers.

More Information on this Audit Type
Claims will be selected based on the analysis of national claims data. Click here for an example of the Y4P0432 additional documentation request letter.

Contact Proactive Medical Review for assistance in analyzing and responding to your SNF PEPPER risks, conducting an audit of SNF documentation & Medicare compliance including COT OMRA use, and preparing for medical review. Proactive clients yielded <3% payment error under active medical review in 2016 when applying partner training, auditing, and medical review response solutions.

By Sheena Mattingly, M.S. CCC-SLP and Amie Martin, OTR/L, CHC, RAC-CT