Review of Skilled Services at Regent Care Center of Laredo, Texas

EXECUTIVE SUMMARY:

Our objective was to determine whether Regent Care Center (Regent) of Laredo, Texas, provided patients with skilled services, particularly infusion therapy services, that were medically necessary and adequately supported by medical documentation. A complete medical review of all skilled services on 50 claims showed that: (1) Regent was properly reimbursed for 6 claims, (2) 38 claims should either be denied or partially denied because skilled services were not medically necessary at the intense level provided in an SNF and/or the RUG level claimed, and (3) 6 claims should be denied because they were not supported by adequate documentation. Because of these errors, Medicare overpaid Regent $136,292 for services that did not meet Medicare requirements. A separate review of infusion therapy services on the 50 claims showed that 2 claims included infusion therapy services that could have been rendered in a nonskilled setting and 29 claims incorrectly included charges for infusion therapy services that Regent did not render. Though these errors did not result in overpayments, SNFs should accurately record charges for services on Medicare claims because CMS uses this information for various rate-setting and payment-refinement activities. We recommended that Regent: (1) refund to the Medicare program $136,292 in overpayments, (2) provide training to its staff to ensure that it fully understands and complies with SNF medical necessity requirements so that future claims comply with these requirements, (3) ensure that its staff follows controls in place so that all Medicare claims are supported with adequate medical documentation, (4) reclassify the improperly reported pharmacy services and submit a revised Medicare cost report, and (5) establish adequate controls to ensure that claims are properly coded. In its comments to our draft report, Regent agreed with our recommendations.