We often hear this a lot: “I thought it was just part of getting older.“

Over time, you may notice small changes. Getting up from a chair takes more effort. Walking does not feel as steady as it used to. You may start avoiding certain activities because they feel harder or less safe. Memory changes may also begin to show up and are often assumed to be normal aging.

While some changes do come with age, other changes are a sign that your body is having more difficulty with everyday tasks than it should.

Signs You Shouldn’t Ignore

• Getting up from a chair or walking feels harder than it used to
• Feeling less steady on your feet or experiencing a fall
• Everyday tasks like dressing, bathing, or toileting take more effort
• Avoiding activities because they feel more difficult or less safe
• Memory changes are becoming more noticeable than before
• Changes in speech, swallowing, or following conversations

How Can Therapy Help?

Talk with your doctor if you have noticed changes in your strength, balance, walking, memory, communication, or ability to do daily activities.

Ask if Physical Therapy, Occupational Therapy, or Speech Therapy could help. Therapy can address these changes early and help you maintain your independence and continue doing the things you enjoy.

CMS-approved Recovery Audit Contractor (RAC) activity continues to expand, with recent focus areas now including therapy claims billed with the KX modifier. These complex reviews apply to outpatient therapy and professional therapy services, including physical therapy, occupational therapy, and speech-language pathology claims.

At HTS, we closely monitor regulatory and audit trends because we understand that compliance, reimbursement integrity, and documentation quality directly impact both our organization and the facilities we serve. In today’s environment, providers are facing increasing scrutiny related to medical necessity, coding accuracy, and documentation support for skilled therapy services.

The KX modifier specifically indicates that therapy services exceeding the Medicare therapy threshold remain reasonable, medically necessary, and appropriately supported within the medical record. RAC auditors are reviewing documentation to ensure claims meet Medicare coverage criteria, coding requirements, and clinical support expectations.

These reviews go far beyond confirming that therapy was provided. Auditors are evaluating whether the medical record clearly demonstrates:

• Skilled need for therapy services
• Continued medical necessity
• Functional relevance of interventions
• Objective progress toward goals
• Alignment between the plan of care, daily documentation, progress reports, and billed services
• Appropriate coding and billing practices

As audit activity continues to evolve, HTS remains committed to maintaining strong compliance oversight and proactive risk mitigation strategies across our therapy operations. Our approach is designed not only to support documentation quality but also to help protect our facility partners from avoidable compliance exposure.

To support this effort, HTS utilizes multiple layers of oversight and compliance support, including:

• Ongoing education and training for therapy teams
• Internal documentation review processes
• Monitoring of coding and billing trends
• Clinical oversight related to medical necessity and skilled documentation
• EMR workflows designed to support compliant billing practices
• Proactive identification of documentation risk areas

In addition, HTS has continued our two-decade-long partnership with Proactive LTC Consulting to complete therapy chart audits focused on identifying potential gaps, compliance concerns, and audit vulnerabilities before they become larger issues.

These audits provide valuable insight into documentation trends and opportunities for improvement across facilities. Once audits are completed, HTS works collaboratively with therapy teams to review recommendations, implement corrective actions when needed, and strengthen ongoing compliance practices.

At HTS, we recognize that the risks and the rewards are shared. Strong clinical documentation and compliant billing practices protect reimbursement, support quality outcomes, and reinforce the integrity of the services provided to residents. By staying ahead of audit trends and investing in proactive compliance strategies, we aim to be a trusted partner that facilities can rely on in an increasingly complex regulatory environment.

Written by:

Sheena Mattingly, M.S. CCC-SLP, RAC-CT

EVP of Quality & Compliance

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Effective: May 26, 2026
Compliance Deadline: May 26, 2028

What’s Changing

The federal government has finalized a rule requiring standardized electronic submission of “claims attachments.” The clinical documentation that supports billing (nursing notes, doctor’s notes, therapy evals, daily notes, progress notes, discharge summaries, etc.).

• Fax, mail, and manual uploads will be phased out
• Documentation must be sent using standard electronic formats and transactions

Why This Matters to Us

This rule directly impacts how documentation supports claims and how quickly facilities get paid.

• Documentation will be requested and transmitted electronically
• Payers will review information faster and more consistently
• Incomplete or delayed documentation will be more visible and more likely to be denied

To successfully comply with these changes, there are four key areas we need to focus on:

1. Documentation Timeliness

• Payers can request documentation electronically and expect a rapid response
• Delays in documentation equal billing delays or denials

Focus Area:

Assure you are reviewing documentation timeliness expectations (i.e., documentation completed same day or within defined facility timelines).

2. Documentation Quality

Standardized formats make it easier for payers to scrutinize documentation more closely:

• • Identify missing elements
  • Apply consistent audits

Focus Areas:

• Medical necessity is clearly documented across the medical record (nursing notes, doctor’s notes, MDS, therapy notes)
• Functional outcomes are consistently documented

3. Electronic Signatures

• All documentation must include secure, authenticated e-signatures

Focus Areas:

• Timely signatures and co-signatures
• No backlog of unsigned documentation

4. Workflow Discipline

Manual “we’ll send it later” processes will no longer work.

Focus Areas:

• Daily documentation expectations are set and understood by the IDT
• Clear ownership for completion, corrections, and timeline
• Rapid response to documentation requests – the team knows their piece of the puzzle and the timeframe in which it is expected to be done. Members of the team have a designated backup champion for when they are not at work.

Your Power Points

1. Fax Is Going Away

• By 2028, faxed documentation will not meet federal requirements
• Facilities must support fully electronic workflows

2. System Readiness Is Essential

Facilities must ensure their systems can:

• Generate compliant documentation formats
• Integrate with therapy and billing vendors
• Support electronic attachment workflows

3. Vendor Alignment Is Critical

This rule requires coordination between:

• Therapy
• Facility EMR
• Billing partner
• Clearinghouse

A gap in any area can delay claims.

4. Faster Requests = Faster Expectations

• Payers can request documentation electronically
• Facilities must be ready to respond quickly

Delays in documentation completion can and will directly impact reimbursement.

Recommended Workflow Review Areas:

• Delayed or incomplete documentation – Run audits to ensure documentation timeliness.
• Unsigned or improperly signed notes – Assure a good process is in place so that documentation is signed as required.
• Lack of system integration between vendors – Integration between therapy and nursing EMRs can assure more timely access to documentation. If you are already integrated, ensure your integration is operating as intended. If you are discussing integration, reach out to your Regional Director if you have any questions.
• Inconsistent documentation practices across buildings – If you are a multi-site organization, ensure workflow consistencies across your buildings. This aligns expectations and creates an easier audit process.

How HTS is Supporting You

HTS is actively evaluating system readiness and integration requirements as both PCC and Matrix have or are currently undergoing integration modernization.

HTS maintains a dedicated integration lead who drives alignment between systems and rapidly identifies and resolves integration issues between the nursing EMR and therapy EMR.

HTS has already done the following:

• Reinforced documentation timeliness expectations with teams
• Audited for signature compliance
• Provided routine standardized documentation quality assurances across buildings

Next Step for HTS Partner Facilities:

• Engage your EMR, billing vendor, and clearinghouse on readiness
• Assess current reliance on fax/manual processes
• Partner with your HTS Regional Director to streamline workflows

This is not just a billing change, it is a documentation, workflow, and technology shift that will impact reimbursement speed, compliance, and audit risk. Organizations that prepare early will see faster payments and fewer denials.

Written By:

Sheena Mattingly, M.S., CCC-SLP, RAC-CT

Executive Vice President of Quality & Compliance

Healthcare Therapy Services, Inc.

The Fall 2025 Semiannual Report to Congress from the Office of Inspector General (OIG) offers more than a summary of enforcement activity; it provides a window into how healthcare oversight is evolving. While the report spans the full healthcare landscape, its themes carry meaningful implications for skilled nursing facilities (SNFs), particularly as regulators continue to scrutinize quality, documentation, and data integrity.

A Growing Enforcement Footprint

At a high level, the OIG reported approximately $19 billion in total monetary impact for fiscal year 2025, reflecting recoveries, cost savings, and identified overpayments. This reinforces both the scale and seriousness of federal oversight.

Just as important as the dollar amount is how enforcement is being carried out. The report highlights a continued shift toward:

• Data analytics to identify outliers
• Cross-agency collaboration
• Proactive identification of risk areas

For SNFs, this means oversight is no longer solely reactive. It is increasingly predictive and data-driven.

Quality of Care Is No Longer Just a Survey Issue

The report and related OIG enforcement activity continue to highlight persistent concerns in nursing homes, including:

• Staffing shortages
• Infection control deficiencies
• Failures to meet basic care standards
• Gaps in employee background checks

While these issues are familiar, the implications are evolving. When these deficiencies result in harm or when providers bill for services that do not meet required standards, they may escalate beyond survey citations into enforcement actions.

Key Shift:

• Quality Concerns → Regulatory Citations
• Quality Failures → Potential Fraud & Enforcement Exposure

This reframes quality as not just a clinical priority, but a compliance and financial risk.

Data Accuracy & Fall Reporting Concerns

A separate OIG report released during the same period found that 43% of falls with major injury were not reported in required resident assessments. While this finding is not from the Semiannual Report itself, it reflects a broader concern about the reliability of reported data.

For SNFs, this raises important questions about:

• Accuracy of Minimum Data Set (MDS) reporting
• Alignment between internal incident logs and submitted data
• Whether reported outcomes reflect actual clinical events

Facilities with unusually low rates of adverse events may not appear high-performing. Instead, they may instead appear inconsistent or inaccurate when compared to other data sources.

Documentation & Payment Integrity Expectations

Across healthcare programs, the OIG continues to identify improper payments tied to insufficient or unsupported documentation. While much of the focus is on Medicare Advantage, the expectation applies broadly.

For SNFs, this reinforces a fundamental principle:

• If it is not documented, it is not defensible

Areas that warrant particular attention include:

• Skilled need justification
• Therapy services and intensity
• PDPM drivers and coding accuracy
• Hospitalization and rehospitalization documentation

As analytics become more advanced, billing patterns that deviate from peers or that lack supporting documentation are more likely to be flagged.

Workforce Compliance Is a Risk Area

The OIG’s identification of failures in background checks and registry screenings signals that workforce compliance is under increasing scrutiny.

This elevates HR processes into the compliance spotlight. SNFs should ensure:

• Background checks are completed prior to hire
• Abuse and neglect registries are consistently queried
• Documentation is complete and auditable

Inconsistent hiring practices are no longer just operational gaps; they are potential compliance vulnerabilities.

Growth Attracts Scrutiny

The report also highlights areas of rapid spending growth across healthcare, reinforcing a consistent OIG pattern: high-growth areas attract attention.

While not SNF-specific, the implication is clear. Providers should closely monitor trends such as:

• Therapy utilization patterns
• Length of stay variations
• High-acuity coding categories
• New or expanding service lines

Any significant deviation from industry norms should be understood, explainable, and documented.

The Bigger Shift: From Reactive to Predictive Oversight

Taken together, the Fall 2025 report reflects a broader transformation in how oversight is conducted.

Facilities may face scrutiny not because of a specific event, but because their data suggests risk.

What SNF Leaders Should Do Now

To align with this evolving environment, providers should focus on:

• Validating Data Accuracy
  • Ensure MDS, incident reporting, and documentation align
• Strengthening Internal Audits
  • Focus on falls, therapy utilization, and coding
• Aligning Documentation with Billing
  • Every billed service should be clearly supported
• Auditing HR Compliance
  • Apply the same rigor as clinical reviews
• Monitoring Internal KPIs
  • Identify and investigate outliers early

Your Power Points

The Office of Inspector General is not just identifying problems; it is signaling how providers will be evaluated moving forward.

For SNFs, success will depend on the ability to ensure that all of the items below are consistently aligned and defensible.

Care is Delivered → Care is Documented → Care is Reported → Care is Billed  

Today, the question isn’t simply whether care occurred. It’s whether you can prove it in a way that stands up to scrutiny.

Written By:

Sheena Mattingly, M.S. CCC-SLP, RAC-CT  |  Executive Vice President of Quality & Compliance

About Sheena:

Sheena Mattingly is a Speech Language Pathologist and the Executive Vice President of Quality and Compliance for Healthcare Therapy Services, Inc. Sheena has a passion for advocacy and is the Chair of the Advion Compliance Committee, addressing critical and emerging topics including: policy development, corporate compliance strategy, artificial intelligence in healthcare, and denials management. She is active in her advocacy role for post-acute care providers by meeting with legislators on Capitol Hill to discuss issues that directly impact providers, clinicians, and patient care. Sheena serves as a member of the Advion Data Compliance Committee, which allows her to present data findings to CMS that ultimately shape fair and sustainable payment methods.