MDS Data Its Influence on Medicare and Medicaid Payment

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MDS Data Its Influence on Medicare and
Medicaid Payment

• Presented by
• Leah Klusch
• Executive Director
• The Alliance Training Center
• 330-821-7616
• leahklusch_at_sbcglobal.net

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Making the Connection

• Regulatory risk issues this increases with case
  mix remember the MDS is an attested document.
• Payment issues in the industry. Many case mix
  platforms for comparison. Basic system is the
  same rate setting issues are unique to the
  states.
• Strategies to improve payment under Medicare and
  Medicaid (in case mix states) looking at
  accuracy, ARD issues and ADL data collection.
• Impact of Restorative programs on regulatory risk
  and improved payment (low rehabilitation) the
  last gold mine of Medicare so to speak.
• Impact of Data Base quality and overall
  success,accuracy is essential and expected

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Do You KnowWho Writes Your Paycheck?

• Think about this where does your payment come
  from and who is in charge of that process?
• Who is really in charge and who do they work for?

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THE ANSWER TO THESE QUESTIONS IS USUALLY A
SURPRISE

• Ask yourself do you even know the answer to
  these questions?
• Who is responsible? What is their training and
  what resources do they have?
• Do they understand their responsibility to the
  operational, clinical and financial success of
  the facility?

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Data Base Accuracy Who
is in Charge?

• Accuracy impacts your regulatory risk and the
  data profile of your facility in the federal data
  base.
• Who monitors accuracy? It should not be the
  people doing the form.
• How do you audit the forms and records?
• What is the consequence of poor data?
• Lets talk about the risk and liability.
• AA9 The Attestation Statement your staff
  certify the data is accurate. Do you and they
  understand what that means in an audit or a fraud
  investigation.

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RUG III Payment System

• Begins with the MDS Data Base required in all
  buildings aggressive schedule of assessments
  assessment data creates the payment grouping and
  the level of payment within the grouping
• ADL scores can increase payment poorly managed
  in most buildings some of the most inaccurate
  data in the MDS data base
• Payment groupings are not being used adequately
  or equally
• Examples Rehabilitation groups dominate
  benefits now More diversity of payment
  groupings is positive

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How are RUGs Assigned?

• MDS items that create payment look at the form
  green shading.
• Not all items create same level of payment
• 78 of Medicare payment comes from P1b
  therapies
• Look at the relativity of the item and its
  accuracy to the payment
• Items easiest to audit are numbers so what
  items on the MDS are numerical?
• Each payment item should have a name next to it
  for accountability.

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Structure of the MDS Process

• Where are the rules and regulations about this?
  Try the MDS Manual You should have one.
• Tag 272 this is the beginning
• The MDS Manual who has them- are they updated
  Why do I need to care?
• What is the competency of the persons managing
  this system and who do they report to?
• Do you know the structure?

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When you get homeTake a look a the MDS Manual

• Chapter 1 Attestation Statement regulatory
  requirements
• Chapter 2 Schedules and definitions of the
  assessment types
• Chapter 3 MDS Language and definitions
• Chapter 5 Submission and Correction
• Chapter 6 RUG 53 payment process
• Many helps and supplemental materials
• Then ask Who has the updated manuals and who
  needs them for our process to be compliant and
  accurate?

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Then ask your staff..

• Who is aware of Assessment Reference Periods?
  Everyone should know.
• Where are the updated MDS manuals in the
  building? Who is responsible to communicate the
  updates to the proper team members?
• Who reviews RUG reports? Must have ADL scores to
  be helpful.
• What is the process for data collection for ADLs?
  Who is responsible and accountable is anyone
  monitoring this?
• How do I get reports and who is reviewing reports
  of MDS activity and Rug utilization. All RUG
  reports should have ADL scores. DID I SAY THAT
  TWICE IT MUST BE IMPORTANT!

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RUG Grouping Qualifiers Medicare

• Extensive plus Rehab Group best payment MOST
  ADMISSIONS HERE
• Special Rehab Group watch out for low ADLs and
  high minutes
• Extensive Services must have ADL of 10
• Special Care code qualifiers carefully
• Clinically Complex impact of the depression
  split
• Non traditional groupers less than 1

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RUG PAYMENT GROUPINGS 2007

• LOOK AT THE RUG 53 PAYMENT CHART
• LETS MAKE SOME NOTES

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Rehab RUGs Distribution
8
24
43
24
1
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Medicare RUGs
79
7
7
5
2
(Impaired Cognition, Behavior Only, and Physical
Function Reduced)
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Medicare Payment System Prospective Payment
System It could stand for Please Pay
Something.OrPositively Panic Stricken
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Data That Impacts Payment

• Look at the RUG 53 Payment Chart
• What creates Medicare Payment
• Begin with the requirements Who manages this in
  your building?
• Basic PPS payment facts
• Payment Groupings and
• The impact of one check or code on the MDS
• So why are we so focused on ADL scores???

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Rehab Group Utilization

• High rehab groups get high use not always good
  Not high profit groups Therapy is expensive
  Therapy should not be managing ARDs without
  nursing. Who looks at minutes?
• Not much movement between rehab groups many
  facilities discharge residents from intense rehab
  to no rehab and have negative outcomes
• Very little utilization of Low Rehab category -
  Lack of awareness and understanding of the system
  This is a high profit group! Restorative
  program necessary for this.

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Check out Restorative as a Part A Payment
Grouping Low Rehab

• Very little utilization Why? Lack of
  understanding of the grouper.
• Look at the payment system it is there!
• Use the grouper in two circumstances
• As an initial RUG grouping for the very weak or
  confused resident.
• As a finishing RUG to secure the outcome and
  finalize the rehab program
• As a transitional RUG off of Medicare to long
  term care services or Part B therapy

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Why is this not utilized more?

• Lack of knowledge of the payment system.
• Old ideas about restorative and therapy.
• Lack of training and awareness of the rehab
  models as standards of care and practice.
• Therapy companies do not see this as profitable
  for them they are in business for their
  business not yours!
• Good question !

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Low Rehab How to use it?

• Look at the definitions in the payment system and
  the MDS manual.
• Chapter 6 MDS manual Look at the criterion
  and how it can be used.
• Look at the payment for this and the cost of
  delivery Interesting? Right ?
• Usually this needs to be driven by operations
  Many MDS managers do not understand this and
  remember therapy does not work for them so they
  have no power over this process.
• Suggestion use this grouper when possible it
  is good for the payment and the outcome.

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Lets Look at Training and Competency of MDS
Managers and IDT Members.

• Very important issue.
• Remember - Who Writes the Check?
• Training is essential and must be directed by
  operations.
• MDS managers should report to Administration or
  Operations this is a management job -
• The Power and Accuracy of the data impacts the
  entire payment process and building financial
  stability.

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Remember

• The MDS is not a nursing document it never was
  a nursing document
• The requirement of the regulation is to do a
  functional assessment of the resident not a
  clinical assessment
• Many parts of the data base require
  interdisciplinary data collection and definitions
  .
• Look at where the data is going pay attention
  to three colored items.

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Lets Look at Your Data or Do You Look at the
Right Data?

• Where do you get your reports?
• What data do you review and how often?
• Blending clinical and financial data bases what
  facts need to be on the reports and who needs to
  evaluate them.
• What data dont you see that you need to review?
• Who understands and uses the MDS and financial
  data bases Who has training?
• What difference does this make????????
• What does your software do to you or for you?
  You paid for this- remember?

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Reports that I have trouble with.

• Pivotal reports that show me the quality of the
  operation and payment.
• Usually hard to acquire WHY ???????
• RUG levels and ADLs this is the real picture
• Case history of RUG levels and ADLs
• High, Medium, Low ADL score ranges by week, month
  or resident group(Medicare, Medicaid, Private
  etc)
• hy

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Medicaid and Case Mix

• Now you will be using MDS coding to impact rate
  setting for Medicaid CMI the important stat.
• Impact of proper RUG classification
• Who in your building knows the qualifiers for
  each payment grouping. Reproducability
• Problem MDS items accuracy and documentation in
  the medical record
• ADL issues RUG groups and Audits
• Impact of snapshot dates when is our resident
  population identified for rate setting and
  payment?

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Continued

• As it looks now January 1st and July 1st with a
  14 day forward window and a 92 day backward
  window to capture the most recent MDS data set
  for calculation.
• Each resident in the sample will have a RUG
  identifier from the MDS that will influence the
  rate payment.
• The RUG level must be correct- honest with the
  level of care delivered- that includes the ADL
• The Case Mix will be or could be revised twice a
  year and will depend on the RUG
• Case Mix qualifiers will be subject to post
  payment audits Now this reflects on MDS
  accuracy and compliance.
• Interesting quote from CMS about mistakes and
  charges of fraud

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Continued

• Late in March of 09 the case mix influenced
  payment rates will be determined from total
  census.
• After that rate setting the case mix could be
  driven by the Medicaid population only on the
  census in the building in July, 09.
• This change to a Medicaid only population for
  case mix determination will probably decrease
  the total payment to the building.

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Case Mix Issues

• Case Mix Index is an average of RUG values for
  all included cases.
• What influences Case Mix? sound familiar?
• Three factors of influence beyond the RUG
  qualifiers for the case
• ADL score
• Depression indicators
• Restorative Care

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Continued

• When is case mix rate calculated by the state
  and who is managing that process
• Look at current case mix levels and documentation
  that supports the payment audits are real.
• Small changes in each case can provide large
  changes in payment too much for most MDS
  managers blend of clinical and financial
  knowledge base.
• Remember this is operational not nursing!

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ADLs Monitoring

• At admission Rich accurate ADL scores to begin
  the stay and show the reason for Rehab and other
  services Remember the requirements for Skilled
  Services.
• During the stay ADLs must be relative and
  should show improvement with Rehab and skilled
  nursing services.
• ADLs that are underscored for whatever reason
  produce lower payment for Medicare and Medicaid
  they drive the payment rates Monitor Monitor
  !
• ADL documentation becomes an operational concern.

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Case Example Impact of ADLs

• Where does the data come from the front line
  care givers
• Who understands Bed Mobility, Transfer, Eating
  and Toilet Use?
• Assessment Reference Period everyone should be
  aware.
• Daytime vs. 24 hour scoring Different scores
  and different Payment!
• Most MDS documentation today comes from the day
  shift leaving significant amounts of resource
  utilization out.

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So What is Influencing the Payment Levels at your
Facility?

• Knowledge base of the team clinical and
  financial
• What does our data say Low ADL scores and High
  Rehab Low ADL scores period Correct RUG
  groupings - Accuracy
• Who knows how we get paid and what contributes to
  the process Medicare and Medicaid
• Training and management of the data collection
  team. Do you have an MDS document with each item
  identified Who codes it.
• How do we create reports and manage data to show
  outcomes and proper payment?
• Therapy plays a big part in the equation Make
  them accountable to follow the rules. Part A and
  Part B
• Monitor Utilization or Medicare meeting
  discussion, minutes and outcomes. Discuss census
  management at snapshot dates.
• Remember what PPS stands for Prospective
  Payment - audits are a reality in both programs.

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Make a To Do List

• Who is in charge of the process?
• What is the accuracy of our data?
• Where are the books are they updated last
  update July 08.
• Who codes green items on the MDS name by every
  item.
• What do my reports say remember the RUG and the
  ADL as well as the case history.
• This is management and operations does the MDS
  manager report to nursing?
• Is our software efficient and accurate?

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ALL OF THESE ISSUES COULD IMPACT YOUR MEDICARE
AND MEDICAID PAYMENT IN A BIG WAY
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What are the first three things I am going to do
when I get back to the building?

• 1.
• 2.
• 3.

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Questions ?
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This program was presented to you by

• Leah Klusch
• Executive Director
• The Alliance Training Center
• 330-821-7616
• leahklusch_at_sbcglobal.net
• P.O. Box 3119
• Alliance, Ohio 44601
• Please call for questions and additional
  information or consultation