Ethical Battles in SNF

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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.