Nursing Home RUG Score

Skilled nursing facilities provide care to elderly residents and patients recovering from certain conditions. These long-term care facilities treat patients with many different needs, so a classification system is needed to determine treatment plans and service costs for insurance purposes. 

In the late 1990s, a RUG scoring system was created to assess patients’ care needs and address Medicaid and Medicare payment tiers. RUG stands for resource utilization groups. The current iteration of this system is the RUG III classification system, which is used nationwide to assess patients’ care needs and daily payment structures for nursing homes. 

What is the RUG Score?

Classifying patients in nursing facilities with a resource utilization group ensures that every patient receives the level of care they need at a cost they can afford. Various methods are used to determine RUG values. One method is the Resident Assessment Instrument (RAI), which evaluates a patient’s strengths, weaknesses, care needs, and treatment preferences. 

Another tool used for correct RUG score calculations is the Minimum Data Set (MDS), which assesses the resident’s functional capabilities so nursing staff know how to work with them. A RUG score is also used to determine Medicaid and Medicare reimbursement amounts for LTC nursing facilities, with higher scores typically resulting in higher reimbursement levels. 

The RUG system ensures that facilities receive appropriate funding for their care based on the complexity and intensity of residents’ needs.

How is the RUG Score Calculated?

RUG score calculations are measured in several categories. These categories include rehabilitation, extensive services, special care, impaired cognition, clinically complex, behavioral problems, and reduced physical function. 

A value is assigned to each resource utilization group, and data about the resident is compiled to assign them to a group. This data includes the resident’s condition and the care they receive when the assessment occurs. 

Importance of RUG Scores for Nursing Homes

LTC nursing facilities provide care through the Medicaid and Medicare networks. They must receive reimbursement through these entities to pay for operations, staffing, equipment, and services for residents. 

The correct RUG score calculations for each patient at the facility dictate how much money is required to provide ample care, so a nursing home’s resources depend on accurate classifications. Otherwise, they could run out of money to provide adequate medical care. 

RUG Score and Quality of Care

Since nursing facilities receive revenue based on the collective RUG scores of their patients, quality of care and this classification system go hand in glove. Let’s discuss the relationship between the RUG III classification system and its impact on quality care. 

The Correlation between RUG Scores and Quality of Care

On the one hand, RUG scores are crucial for the resident’s well-being. If that patient requires extensive services and specialized care, a higher score in the RUG III system will result in more care. This system also benefits residents by ensuring each patient is allocated care services based on their needs. 

However, If a resident is assigned an incorrect RUG value or placed in lower-tier RUG III groups, they may not receive the required level of care. 

Potential for RUG Score Manipulation and Upcoding

Skilled nursing facilities do not always operate ethically. Those responsible for assessing RUG III groups could deliberately manipulate a facility’s score to increase revenue from Medicare reimbursements. Assigning an incorrect RUG value to a patient to artificially inflate funding needs is a form of fraud. 

If these upcoding violations are discovered, the facility could be at risk of license revocation or even closure, placing residents in danger of interrupted care. 

Impact of RUG Scores on Staffing and Resources

LTC nursing facilities have a healthcare partnership with Medicare and Medicaid. These networks rely on accurate RUG score calculations to administer reimbursements to these nursing homes. 

A higher RUG score could bring in enough revenue to increase the staffing at a facility, allowing for better care of residents. When more resources are allocated to the facility and are used efficiently, the quality of care increases for all patients. 

Protecting Residents’ Rights

When used correctly, the RUG III classification system directly benefits residents at LTC nursing facilities. However, since RUG score calculations determine the type of care a patient receives, manipulations and incorrect data can lead to poor care. 

In some cases, nursing home abuse and neglect may result from poor implementation of the RUG III classification system. Resident rights must be protected amid this healthcare partnership.

Recognizing Signs of RUG Score Manipulation

Payments to LTC nursing facilities depend on accurate RUG values. If these facilities manipulate the RUG score calculations, they may be guilty of fraud. Residents and families should learn to watch for signs of RUG score manipulations to blow the whistle on potential fraud. 

If you notice that a patient is receiving far less care than they need, it could be due to an incorrect resource utilization group score. 

You can assess patient data to review their RUG score and determine if it’s being inflated beyond actual needs. Check if the determination of medical necessity is excessive. If your nursing home has an LTC online portal, you can use a form status inquiry to access patient records and verify this information.

Advocating for Accurate Assessments

Accurate assessments are essential to avoid fraud and provide sufficient care for every resident. You can play a part in improving the resource utilization group system by advocating for accuracy. Communicate with the care providers to ensure there is clarity surrounding your treatment needs or the needs of your loved one. 

Review medical records thoroughly to search for score inflations or reductions. Some facilities may lower a patient’s RUG score to avoid providing necessary Medicaid services. 

Legal Recourse for RUG Score Issues

If you suspect the submitted Minimum Data Set or Resident Assessment Instrument has used false information to determine a RUG value, you may want to consider taking legal action. RUG score manipulation and upcoding could put you or your loved one at risk of not receiving adequate care, which could result in abuse or neglect. 

Filing complaints against the facility or pursuing a lawsuit may be necessary to rectify the situation, especially if the patient suffers because of the score manipulation. 

Role of a Nursing Home Law Firm

Nursing home lawyers specialize in protecting the rights of residents and their families. If you are not receiving the therapy you need or are suffering other injustices, your health could be at risk. A nursing home law firm can discuss your legal options and help you hold the at-fault party responsible for negligent behavior. 

Assisting with RUG Score Disputes

RUG score disputes are complicated, and facilities are best served by sweeping the issues under the rug. Upholding the integrity of this system is essential to ensure patients nationwide receive the Medicaid or Medicare services they need. 

If you suspect inaccurate RUG score calculations for yourself or a family member, nursing home lawyers can help. They can review assessments and advocate for accurate facility reimbursements, ensuring proper care and resource allocation. 

Protecting Residents from Exploitation

This issue specifically impacts facilities that care for elderly residents. These individuals are much more vulnerable to manipulation, so they may not realize they are being used to abuse a system and increase revenue. 

On the other hand, undervaluing a patient’s needs could lead to low-quality care that puts their life at risk. Experienced attorneys can protect residents and families from nursing home exploitation. 

By holding these facilities to higher care standards and pursuing compensation for legal damages in cases of abuse or neglect, these legal professionals help to improve healthcare for skilled nursing patients. 

Get in Touch With a Nursing Home Lawyer Today!

Do you suspect that RUG scores are being manipulated at the facility where you are staying? Have you noticed a family member not receiving the level of care they should? 

These issues could be evidence of manipulation or upcoding of RUG values to increase revenue or reduce the burden of care on nursing staff. In either case, you have the right to pursue legal action against the facility or staff members in question to hold them accountable for negligence or misconduct. Nursing Home Law Center specializes in representing the interests of nursing home residents and protecting their rights. We offer a free consultation so you can ask questions about your case and determine your legal options. To receive a free case evaluation regarding nursing home RUG scores, call our team today at 800-926-7565 or complete the contact form.