MAC, RAC, MIC, CERT, ZPIC——–They ARE watching you!  Just because the RACs are on a “pause” doesn’t mean that you will be left alone. On the contrary, there are other entities watching you and they may not be looking at only therapy. Most recently, there has been a focus on QAPI (Quality Assurance Performance Improvement) after a government report of adverse events occurring in post-acute care.

DID YOU KNOW?

• Improper Medicare payment to skilled nursing facilities has increased from 4.8% to 7.7% between 2012 and 2013 due to the SNF’s failure to obtain physician and NPPs certification and recertification statements.
• If the physician/NPP certification and recertification process isn’t timely and doesn’t provide all of the medical necessity statements by the physician/NPP justifying the need for the skilled level of care, you will be at risk for improper payments if you are faced with a CERT (Comprehensive Error Rate Testing).
• YES!  You will receive a denial for medical necessity and face the potential for the resident’s entire skilled stay to be recouped.

An acceptable certification statement must be documented stating that the resident needs skilled nursing care or skilled rehabilitation services on a daily basis. Physician/NPP certification must be completed at the time of the SNF admission and recertifications are required 14 and 30 days following admission and then every 30 days thereafter.

WHAT SHOULD THE STATEMENT INCLUDE?

The physician/NPP certification or recertification statement must:

1. State the reasons why a resident has a continued need for care of a condition that was treated as an inpatient at the hospital.
2. Include an estimated time frame that the resident will remain in the SNF.
3. State that the services the resident requires can only be practically provided in a SNF inpatient basis.
4. Provide an explanation of the reason and specific condition if the resident requires a continued stay for a condition other than the one requiring hospital admission.
5. Include the physician/NPP legible signature AND date.

Each facility is responsible for ensuring the physician/NPP certification/recertifications are completed. Review your facility process and tweak where necessary. Involve your physicians/NPPs/medical directors in the process. Finally, ensure the right person is in charge of obtaining these statements and tracking when recertification’s are due. It is important to watch your facility process in motion by inspecting what you expect.