From speaking with colleagues at work in the SNF sector, it appears that there is a constant ethical battle in skilled nursing facilities when it comes to RUG levels and meeting the required minutes set for the patient on a daily/weekly basis, where there is pressure from the rehab directors to meet established minutes for higher RUG levels, although at times clinically, the physical therapist may see otherwise? Can you speak to this from your perspective and experience working in the SNF sector? Do you see this ethical dilemma come up often?
Answer
I think that is one of the biggest issues in the SNF sector. If you look at the information, that has come out from CMS and the OIG over the last couple years, they have really noticed an elevation in the RUG levels. There are more rehab ultrahigh RUG levels over the last couple of years that there have been and it is trending upwards. Medicare is saying if there has not been a change in the types of patients that are residing in skilled nursing facilities; so what is the issue? Unfortunately as a field, we have not been able to identify if there indeed has been a change in the types of patients. One thing we have noticed is generally patients do better with more therapy than they do with less therapy. Here is the key. Patient care is always driven by patient need. It should never be a business decision. If we are looking at RUGs and we are saying your RUGs are low, that is not a proper discussion. If a manager said, “Hey, you are working with Mrs. Smith and it looks like you have numerous goals that are not being addressed; let’s talk about those,” that is the right discussion. It should go back to the clinical rationale. If we can stick to the clinical discussion, that is the right discussion. It should never be a RUGs discussion for sake of RUGs levels. Do what is right for the patient and stand firm on that because at the end of the day, you are the one who signs your documentation and submits that billing, not your rehab manager.
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Mark E. Hyder, PT, DPT, RAC-CT
Dr. Hyder graduated from the University of Oklahoma's physical therapy program in 1995. He is an experienced speaker and presenter, and has spent most of his career as a PT in the skilled nursing sector providing patient care, developing programs, and providing multiple site management. Dr. Hyder completed his transitional DPT, with an emphasis on Practice Management and Administration, in 2011 through Rocky Mountain University of Health Professions. He is currently the Vice President of Clinical Services for Brighton Rehabilitation.
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