Ask the legal expert: Legal concerns for MDS and RUG-IV

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Attorney John Durso, Ungaretti & Harris LLP
Attorney John Durso, Ungaretti & Harris LLP

Question: Do you foresee any legal concerns or cautions brought about by the implementation of the new MDS 3.0 and RUG-IV payment systems?

Yes and no. Version 3.0 of the Minimum Data Set (MDS 3.0) instrument and the corresponding case-mix classification model, Resource Utilization Group (RUG IV), which were implemented Oct. 1, make significant changes to long-term care reimbursement. These changes, however, relate mainly to the financial, operational, and clinical practices of long-term care providers and raise few, if any, unique “legal” concerns.

Additionally, RUG-IV virtually eliminates the “extensive rehabilitation services” category of service and re-weights the lower rehabilitation services. Despite this change, the overall number of RUG categories will increase from 53 to 66. RUG-IV also reduces certain look-back periods so that providers may only count, in RUG calculations, services rendered after SNF placement. This reduced look-back period will decrease the number of residents in higher-paying RUG categories.

Successful facilities will develop clinical compliance programs and refocus the efforts of staff to meet Centers for Medicare & Medicaid Services goals.

One initial step providers should take is to evaluate the change in service categories based on the type of residents they admit and the needs of those specific residents. A self-evaluation of that sort will allow management to narrowly tailor policies to the requirements of the MDS 3.0-RUG-IV framework. These sorts of strategic approaches will allow long-term care facilities to improve the quality of resident care and accurately document the care they provide to ensure they receive proper reimbursement for their services.

Please send your legal questions to John Durso at ltcnews@mcknights.com

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