215 Hirsch RAC- - Wisconsin Hospital Association Hirsch RAC-.pdf3/25/2014 2 – Physician kickbacks- rent, employee salaries, student supervision – Direct admit SNF patients from

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Case Management Hors d’oeuvres-Tasty Bites for the Mind

© Accretive Health, Inc. All rights reserved

Ronald Hirsch, MD, FACPV.P. Regulations and Education Group

Physician Advisory [email protected]

(847)471-7273

Why are we here?

● “If the MDs don’t develop quality measures, the MBA’s will.”– * Michael Leavitt, Secretary of Health & Human Services; AMN Dec 4, 2006.

● “If we don’t do it ourselves, Congress will make a law forcing us to do it.”

– Ian Jones, MD, VPMA, Sherman Hospital, Elgin, IL

● We have not been good guardians of the Medicare Trust Fund so they had to mandate…– Core measures

– Joint Commission Patient Safety Goals

– Never Events

– And now the RAC, Prepayment reviews, OIG audits, VBP


SPINE SURGEON ARRESTED ON CHARGES HE PERFORMED

UNNECESSARY SURGERIES AND BILLED HEALTH INSURANCE PROGRAMS

The indictment alleges that Durrani would tell the patient the medical situation was urgent and that back surgery was needed right away. He would also falsely tell the patient that he/she was at risk of grave injuries without the surgery. For cervical spine patients, Durrani would

often tell a patient that there was a risk of paralysis or the head

would fall off if the patient was in a car accident because there was almost nothing attaching the head to the patient’s body.

www.justice.gov/usao/ohs/news/08-07-13.html


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– Physician kickbacks- rent, employee salaries, student supervision

– Direct admit SNF patients from distant SNF, bypass closer hospitals

– Admit patients without acute medical needs

– Pulmonologist oversedates patients so trach needed and hospital gets DRG 003- weight- 17.8 (joint replacement- 2.87) and MD gets more visits

www.justice.gov/usao/iln/pr/chicago/2013/pr0416_01a.pdf


Sixth National Medicare RAC Summit, November 8, 2011 Lessons for Providers from the First Year of ZPIC Audits

Steve Lokensgard, Faegre & Benson LLP

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The Spectrum of Medicare Auditors


Fighting the Auditors

Sherman Hospital -2011 Medicaid OIG audit- 14 denials- $75,000Appealed all 14, OIG temporarily halts audits, 13 of 14 overturned. Contractor quality clearly poor.

NYU Langone Medical Center does not agree with the OIG findings on 101 inpatient short stay claims worth $474,931. Based on the clinical indications demonstrated by the patient and supported by the documentation in the medical record we believe the physician determination for admission is justified and medically necessary and we will exercise our rights to have a claim re-determination conducted by our Medicare Administrative Contractor, National Government Services. Therefore, we will appeal these claims with National Government services.


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“In other words, there should be deference afforded to the patient's physician and this critical, complex medical decision should not be summarily second-guessed by the OIG after the fact. Given that Tulane provided care and treated the patient in the status as ordered by his/her physician, and given the clinical presentation of the patient at the time of service, Tulane submits that it acted in accordance with Medicare policy, as further confirmed by the results of the independent third party physician review of the cases.”

http://oig.hhs.gov/oas/reports/region6/61200034.asp


First Taste- Readmissions

●Why 30 days?

– Why not 23 days? 17 days? 8 days?


2014 IPPS Rule Changes

2014 IPPS Rule

● 2% penalty based on July 1, 2009 to June 30, 2012 data

● Added exclusions for planned readmissions after acute MI– 15 new discharge status codes established

● Added COPD and total hip and knee arthroplasty for FY 2015


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What about SES and unrelated

readmissions?

● Many safety-net providers and teaching hospitals do as well or better on the measures than hospitals without substantial numbers of patients of low socioeconomic status. Our analyses also show that adding socioeconomic status to the risk-adjustment has a negligible impact on hospitals’ risk-standardized rates.

● Regarding other types of unrelated readmissions, we currently do not seek to differentiate between related and unrelated readmissions because readmissions not directly related to the index condition may still be a result of the care received during the index hospitalization. For example, a patient hospitalized for COPD who develops a hospital-acquired infection may ultimately be readmitted for sepsis. It would be inappropriate to treat this readmission as unrelated to the care the patient received during the index hospitalization.


Post-Hospital Syndrome

● NEJM January 10, 2013– Readmission cause same as index admission only ~35% of time

– deprived of sleep,

– experience disruption of normal circadian rhythms,

– are nourished poorly,

– have pain and discomfort,

– confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and

– become deconditioned by bed rest or inactivity.


Does it really save money?

Study: NC cuts readmissions by 20% among sickest, poorest patients

The research team looked at 13,476 Medicaid patients with complex chronic conditions who received a transitional care assessment or intervention by a program care manager following a hospital discharge July 2010 through June 2011. The study included patients discharged from 120 hospitals, patients enrolled in 1,325 primary care medical homes and residents of 99 of North Carolina's 100 counties. The project involved 800 nurses and social workers doing intensive follow-ups with Medicaid patients

Savings- 13,476 patients x 20%= 2,700 admissions prevented x $10,000 per admit= $27,000,000

Costs- 800 nurses x ~$50,000/yr = $40,000,000


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Hospitalists No Panacea for HF

Greater use of hospitalists for managing patients with heart failure did not improve outcomes through 30 days, researchers found.

In fact, every 10% absolute increase in the percentage of patients treated by a hospitalist was associated with a slightly increased risk of 30-day mortality after accounting for patient and hospital characteristics (RR 1.03, 95% CI 1.00-1.06), according to Robb Kociol, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues.

Greater hospitalist use was associated with a small decrease in length of stay (by 0.09 days, 95% CI 0.02-0.16) and better adherence to established performance measures, but it was not related to 30-day readmission rates.

JCHF. 2013;():. doi:10.1016/j.jchf.2013.07.001


New Law being proposed

Establishing Beneficiary Equity in the Hospital Readmission Program Act -- Rep. Jim Renacci (R-Ohio)

- Risk adjust for hospitals with high dual eligible population

- Remove transplant, ESRD, burns, trauma, psychosis and substance abuse

- Mandate MedPAC study of 30 day time frame

- Exclude non-compliant patients identified by V codes


My personal opinion on Readmissions

● Make the hospitalists actually spend >30 minutes with patient on discharge

● Sit down next to bed, on side away from the door

● Do med rec themselves, looking at home meds carefully

● Use generics- no fancy stuff that needs prior auth

● Type out discharge instructions themselves in plain language

● Call a family member on every discharge and explain course

● Do the discharge summary on the day of discharge

● Get a message to the PCP on hospital course and get patient appt

● Follow up on pending tests after discharge


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What’s the money behind readmissions?

Penalty assessed on base DRG payment, not full DRG

Wheaton Racine Froedtert

Readmit penalty % 0.27% 0.09%

HF w/MCC-base $10,406

penalty $28.10 $9.44

Total DRG pay $12,795 $17,396

True penalty % 0.22% 0.05%


Transfers

Q2.2: How should providers calculate the 2-midnight benchmark

when the beneficiary has been transferred from another hospital?

A2.2: The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services shall be excluded from the physician’s admission decision. (Note: for the purposes of this question, hospital is defined as acute care hospital, long-term care hospital (LTCH), critical access hospital (CAH), and inpatient psychiatric facility.)


Does that mean…?

Two days at hospital A for NSTEMI, sent to hospital B for cath, hospital B can admit as inpatient for cath, even if the test may be negative and the patient goes home 4 hours later?

WPS – Yes it does!


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What about the transferring hospital?

Wow this guy is sick, we need to get him to the Mecca ASAP. I have called them already. Stick him in the ICU until they call with a bed--> Observation since leaving in less than 2 MN. If he ends up not going, then the hospital can admit at any time.

Wow this guy is sick, get him to the ICU and if he does not get better, we may need to transfer him to the Mecca in the next day or two--> Inpatient since they expect him to stay and can still bill inpatient even if he gets worse and leaves for the Mecca prior to the second midnight.


Medicine-

Case Example v 4.0

● 78 yr old male with COPD, presents Monday at 6 am with COPD exacerbation. Patient is an ED “familiar face” with a visit once monthly, lasting 1-4 days. Of course he still smokes, even with his oxygen. Tried nebulizer at home without success.

● In ED given 3 nebs, IV steroids, CXR, labs normal, getting a little better, at 9 am Monday ED doc reevaluates and determines patient cannot go home, “mild exacerbation.” Calls admitting MD who agrees “one day in house.”


What status does patient need?

● What is the expectation of LOS based on condition, treatment and risk?

● Presented Monday 6 am, it is now Monday 9 am, may be able to go home Tuesday

● Monday midnight = 1 midnight

● Place in observation on observation unit


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Case Example v 5.0

● 78 yr old male with COPD, presents Monday at 10 pm with COPD exacerbation. Patient is an ED “familiar face” with a visit once monthly, lasting 1-4 days. Still smokes, even with his oxygen. Tried nebulizer at home without success.

● In ED given 3 nebs, IV, CXR, labs normal, pO2 normal, getting a little better, at 1 am Tuesday ED doc reevaluates and determines patient cannot go home “mild exacerbation.” Hospitalist agrees, “one day in house.”


What status does patient need?

● What is the expectation of LOS based on condition, treatment and risk?

● Presented Monday 10 pm, it is now Tuesday 1 am, may be able to go home Wednesday

● Monday midnight + Tuesday midnight = 2 midnights

● Admit as Inpatient, even though will be only one inpatient midnight

● Same patient, same care, same LOS, different status because time of presentation was different! (Does he go to your obs unit?)


Forgot to Admit a Patient

Patient placed observation or in recovery over 1 MN, not able to go home next day, continues care in hospital. After 2nd MN, ready to go home.

CMS says: Since patient met benchmark, admit as inpatient then discharge. Admit and Discharge dates are the same.

Will likely be audited but should pass.


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Dec. 19, 2013 ODF transcript

So, this is Marc Hartstein, I’m the director of the Hospital and Ambulatory Policy Group. If the physician admits the patient then the patient – I mean – this patient has met the two midnight benchmark because the patient’s been in the hospital more than two midnights.

The physician may write an order to admit and the patient could also be discharged that same day. However –(inaudible) – the patient would only be considered an inpatient for the time they spent from the time of the order until the time of discharge if that would be one inpatient day.

http://goo.gl/spP9sX


Doctor Doesn’t Sign Admit Order

Commencement of inpatient status-

Inpatient status begins at the time of formal admission by the hospital pursuant to the physician order, including an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)) that is countersigned timely, by authorized individuals, as required in this section. If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered to be an inpatient. The hospital stay may be billed to Part B as a hospital outpatient encounter.


What does this mean?

In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (TOBs 13x, 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met:

a. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;

b. The hospital has not submitted a claim to Medicare for the inpatient admission;

c. A physician concurs with the utilization review committee’s decision; and

d. The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.

SE0622 Condition Code 44


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Noridian: Q32. Can a practitioner change his/her mind and request a change

from inpatient to outpatient without involvement of UR committee? A32. No, the change has to involve the UR committee.

NHIC: Q18: On the CMS website for their question and answers, question

#9972 states “The hospital may not change a patient’s status from inpatient to outpatient without UR committee involvement.” Please clarify: can the attending physician change it on his/her own? A18: No; an attending physician may not make a unilateral decision-CC-44 definition requires UR involvement.

WPS: Q25: When may we vary from the doctor’s order for inpatient admission (for example, suppose the doctor orders inpatient admission and the next day changes the status to observation based on test results)?

A25: The physician may not change a patient’s status from inpatient to

outpatient without involvement from the UR Committee.


So does that mean…

…condition Code 44 only required if admit order is signed?

…doctors can unilaterally change their mind?

…patients do not need to be notified their status has changed?

…a 5 day admission after a hip fracture with an unsigned admission order before discharge is also outpatient part B and not eligible for SNF?


Related Claims

The MAC, Recovery Auditor, and ZPIC have the discretion to deny other related claims submitted before or after the claim in question. If documentation associated with one claim can be used to validate another claim, those claims may be considered “related.” Claims may be “related” in the following EXAMPLE situations:

o An inpatient claim and associated documentation is reviewed and determined to be not reasonable and necessary and therefore the physician claim can be determined to be not reasonable and necessary.

o A diagnostic test claim and associated documentation is reviewed and determined to be not reasonable and necessary and therefore the professional component can be determined to be not reasonable and necessary.


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No Observation over 48 hours

“…The decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in necessary hospitalizations should not pass a second midnight prior to the admission order being written.”

IPPS Final Rule CMS-1599-F, Federal Register, p. 50946

If their medically necessary care is finished and the patient stays, the observation services should be billed on a separate line-revenue code 0762

if give an ABN, use -GA

if writing off the hours, use –GZ

How do you bill hospital convenience hours? NO CLUE!!!!


Certification

Required Elements

Authenticated admission order by doctor

Reason for hospitalization

Estimated LOS

Discharge plans

What is really needed

Authenticated Admission order by doctor

H&P and orders


CMS Q&A

The physician’s order contained a checkbox with pre-printed text stating “The beneficiary is expected to require 2 or more midnights of hospital care.” The physician’s plan of care, however, stated that the beneficiary was to have diagnostics performed post-operatively, with a plan to discharge in the morning if stable. The beneficiary was discharged the following day as planned, after a 1-midnight stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written.


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CMS reminds providers that attestation statements indicating the beneficiary’s hospital stay is “expected to span 2 or more midnights” are not required under the inpatient admissions policy, nor are they adequate by themselves to support the expectation of a 2-midnight stay. Rather, the expectation must be supported by the entirety of the medical record.


How to Rebill after discharge

Must follow CFR 482.30- conditions of participation for Utilization Review

Must occur within 1 year of date of service

1- Determined by one member of UR Committee to be not medically necessary if physician concurrence or

2- Determined by two members of the UR Committee to be not medically necessary if physician does not concur

3-Written notice to patient, hospital and practitioner(s) within 2 days


Normal Inpatient Stay


Arrive ED

Admit Discharge

Inpatient Part A 111 claimDRG payment

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Condition Code 44 near

discharge


Arrive ED

AdmitDischarge

Outpatient Part B 131 claimAPC for ED visit

CC 44To Outpt

Condition Code 44 with > 8 hrsobservation


Arrive ED

Admit Discharge

Outpatient Part B 131 claimAPC for Observation (incl ED visit)

CC 44To Outpt Obs ordered

Failed CC 44


Arrive ED Admit Discharge

Outpatient Part B

131 claim

Inpatient Part B

121 claim

No pay inpatient 110 Claim

Failed CC44

then

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Doctor does not sign the

Admission Order


Arrive ED

Admit

Discharge without authenticated order

Outpatient Part B 131 claimAPC for ED visit

No Observation since no orderBeneficiary Rights Violated

When does CMS care about coverage?

When they pay for it!

-Was stay medically necessary? If yes, pay DRG, hospital may do “anything” to patient they feel is indicated for patient

-Did any service change the DRG? If yes, evaluate medical necessity of that service

-Were any services billed separately? If yes, evaluate each service for medical necessity- New technology add-on payments, blood clotting elements


● NCD’s and LCD’s available for many procedures– Pacemakers, ICD’s, total joint replacement, cataract extraction

● If no NCD/LCD, “acceptable standard of practice” applies– Medicare contractors, in determining what “acceptable standards of practice”

exist within the local medical community, rely on published medical literature, a consensus of expert medical opinion, and consultations with their medical staff, medical associations, including local medical societies, and other health experts

– By way of example, consensus of expert medical opinion might include recommendations that are derived from technology assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or the American College of Physicians, or findings published by the Institute of Medicine.


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CMS retained Performant Recovery, Inc. to carry out the Recovery Audit (RA) program in Region A

Medical indications for the coverage of Blepharoplasty – eyelid lifts are outlined in 42 CFR 405.926, 42 CFR 405.980, 42 CFR 405.982, 42 CFR 405.984; 42 CFR 405.986, the Medicare Claims Processing Manual, CMS Pub. 100·04, Chapter 34, Sections 10.6.1 and 10.11, and Medicare Program Integrity Manual, CMS Pub 100-08, Chapter 3, Section 3.5.1; NovitasLocal Coverage Determination L27474 and National Government Services Local Coverage Determination L26448.


What is your new service evaluation procedure?

● Do you look at…– FDA/CMS/Insurance approvals?

– Medical Necessity Guidelines?

– Equipment costs- fixed and per procedure?

– Staff training?

– Reimbursement- DRG / APC?

– Precertification requirements?

– Expertise of physicians?

– Who is going to be patient #1 and do they know that?

DME Face to Face

As a condition for payment, section 6407 of the Affordable Care Act requires a physician to document that the physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) has had a face-to-face encounter examination with a beneficiary in the six (6) months prior to the written order for certain items of Durable Medical Equipment (DME).

The contractor shall verify that the face-to-face documentation includes information supporting that the beneficiary was evaluated or treated for a condition that supports the item(s) of DME ordered.

Change request 8304, May 31, 2013


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MAC Probe Audit

Service Wide Review Results for Inpatient Prospective Payment System (IPPS) Claims for Diagnosis Related Group (DRG) 036: Carotid Artery Stent Procedure without Complications/Co-Morbidities (CC)/Major Complications or Co-morbidities (MCC)

50 records reviewed- 86% denial rate

-The severity of the signs and symptoms exhibited by the patient, and / or the intensity of service did not warrant an inpatient admission to an acute level of care and the procedure is not Addendum E Inpatient only list.


CERT Denial

● Beneficiary had a fall in July 2010 but no treatment or office visit reports submitted before this admission on 5/17/12. MRI showed disc collapse and some stenosis but no evidence of abnormal movement on flexion and extension views. No documentation of conservative treatments, PT, or meds. his post op course was extremely complicated with ileus, non ST elevation MI, V tach and cardiac arrest. He had possible pulmonary embolus and had IVC filter placed which was appropriate. Admission was not reasonable and necessary as procedure didn't meet criteria. IVC filter was appropriate to deal with the post op complication but he shouldn't have been in hospital anyway. JMD. Disagree with elective inpatient admission and invasive procedure


SNF part A coverage

● 42 CFR 409.30- The beneficiary must have been hospitalized in a participating or qualified hospital or participating CAH, for medically necessary inpatient hospital or inpatient CAH care, for at least 3 consecutive calendar days, not counting the date of discharge and receive the needed care within 30 calendar days after the date of discharge from a hospital or CAH.

● Rebilling part B- status remains inpatient


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When the facts that come to the intermediary’s attention during the course of its normal claims review process indicate that the hospitalization may not have been medically necessary, it will fully develop the case, checking with the attending physician and the hospital, as appropriate. The intermediary will rule the stay unnecessary only when hospitalization for 3 days represents a substantial departure

from normal medical practice. MBPM Ch. 8, 20.1

For purposes of qualifying for SNF coverage, an inpatient hospital stay that is retroactively denied after SNF admission could still meet the relatively broad definition of medical necessity set forth in the manual provision cited above. 2014 IPPS final rule page 1709


The ``substantial departure from normal medical practice'' language was developed specifically to target those rare situations where the 3- day stay is clearly unnecessary by any reasonable standard. For example, the MAC could determine that a hospital stay was medically unnecessary for purposes of qualifying for post-hospital SNF coverage in situations where the care is so clearly unnecessary that it appears that the patient was admitted to the hospital solely for the purpose of attempting to qualify the beneficiary inappropriately for ``posthospital'' SNF benefits.

» 2014 IPPS Rule P. 50921


Outpatient Chemo- the next frontier

● Huge opportunity for CMS to recoup billions

● CMS covers drugs and biologics for anti-cancer therapy chemotherapy if they are used as per FDA- approved indications. CMS also pays for off-label, medically accepted indications if they are supported in either one or more of the compendia (4) or in peer-reviewed medical literature (26 journals) specified in the Medicare Benefit Policy Manual Chapter 15.


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Kyprolis™ (carfilzomib)

● approved for the treatment of patients with multiple myeloma who have received at least two prior therapies, includingbortezomib and an immunomodulatory agent, and have demonstrated disease progression on or within 60 days of completion of the last therapy.

● The medical record must clearly document the patient‘s prior chemotherapy regimens, disease progression and body surface area.

● $9,550 for a typical cycle of six vials, cycle every 28 days

● Currently, no data are available that demonstrate an improvement in progression-free survival or overall survival.


Provenge- prostate cancer

● $33,000 per dose, 3 doses 2 weeks apart● Documentation regarding means of castration (e.g., surgically by bilateral

orchiectomy or documentation of 3 or more months of chemical castration and agent used or the medical documentation from the treating physician includes a clear statement of failure of chemical castration)

● Medical records should specifically address evidence of progressive disease after surgical or chemical castration (examples may include: changes in size of lymph nodes or parenchymal masses on physical examination or radiographic studies, bone scan progression, PSA progression, etc.)

● Evidence that the patient is asymptomatic or minimally symptomatic (should include a note about the patient’s level of activity)

● Each claim must stand alone, meaning the documentation in the submitted record must support the medical necessity of the service(s) billed on each individual claim.


In your outpatient infusion/onc center

● Does someone review the records to see if the right drug is being given in the right order?

● Just because it is not covered, does not mean it cannot be given– ABN for outpatient

– HINN 11 for inpatient


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Dessert- Press-Ganey- my rant

● Last February researchers at UC Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on health care and prescription drugs. They were 12% more likely to be admitted to the hospital and accounted for 9% more in total health care costs. Strikingly, they were also the ones more likely to die.

● Why? The UC Davis authors posit that the most satisfied patients have a higher mortality rate because they receive more discretionary services–interventions that carry a risk of adverse effects. Even routine screenings for diseases like prostate cancer can lead to unnecessary drugs and operations with allergic reactions and surgical complications that leave patients worse off.

● Patient satisfaction was independent of hospital compliance with surgical processes of quality care and with overall hospital employee safety culture, although a few individual domains of culture were associated. Patient satisfaction may provide information about a hospital's ability to provide good service as a part of the patient experience; however, further study is needed before it is applied widely to surgeons as a quality indicator.

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Hospitals with unhappy patients still provide high-quality

care

Under the Lieberthal model, a patient in a highly-rated hospital might dislike the noise and bad food, but survive his life-threatening heart attack. "Based on this study, the hospitals that have the best survival outcomes are not doing the best job of satisfying patients," said Dr. Lieberthal.

www.sciencedaily.com/releases/2013/09/130930140450.htm

www.fiercehealthcare.com/story/hospitals-unhappy-patients-still-provide-high-quality-care/2013-10-01

© 2013 Accretive Health, Inc. All rights reserved.

The Perfect Storm

● Purdue invents Oxycontin and wants to sell lots

● Purdue creates “pain is a disease” campaign to sell more

● JC buys into it and declares pain a “vital sign”– Nurse, get me the pain measuring rectal probe please”

● Press-Ganey invents patient satisfaction surveys and wants to sell lots of them

● P-G creates “high patient satisfaction = high quality care” campaign to sell more

● CMS buys into it and starts paying hospitals based on patient satisfaction

● Hospitals start insisting doctors satisfy patients

● Patients get more opiates for minor pain to satisfy them

● A small number of these patients become dependent

● Other patients realize that doctors are being measured and demand opiates in order to be “fully satisfied with their care”

● And we have an epidemic of opiate abuse!

Thanks!

Questions?

[email protected]

Case Management resources and videos at

www.ronaldhirsch.com


Documents

215 Hirsch RAC- - Wisconsin Hospital Association Hirsch RAC-.pdf3/25/2014 2 – Physician kickbacks- rent, employee salaries, student supervision – Direct admit SNF patients from