CMS might need six months before starting to reprocess nursing home payment claims, agency says

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CMS might need six months before starting to reprocess nursing home payment claims, agency says
CMS might need six months before starting to reprocess nursing home payment claims, agency says

It could take federal regulators six months or more to devise and implement a new payment scheme for nursing homes after a new resident assessment tool goes active Oct. 1, an official with the Centers for Medicare & Medicaid Services said Thursday.

The plan currently is to use the proposed RUG-IV (Resource Utilization Group-IV) payment groupings to pay claims for the new MDS 3.0 on an interim basis and then recalculate payment levels when a “hybrid RUGs-III” system is settled upon, said CMS's Sheila Lambowitz during the agency's monthly SNF Open Door Forum conference call. MDS (Minimum Data Set) 3.0 is scheduled to take effect in October, while RUG-IV implementation is set to take place in October 2011. 

Much of the anxiety, not to mention the hybrid payment system, would not be an issue, she pointed out, if Congress passes a bill that would eliminate a postponement of the full RUG-IV system. The health reform bill passed earlier this year pushed implementation back a year. It was supposed to go into effect with MDS 3.0 this October.

“We are looking at all things on a contingency basis,” Lambowitz said to the nearly 800 listeners on the call. “I think it will probably take us a minimum of six months to get the new hybrid grouper processed and in place. At that time, we'll look at reprocessing claims.”

Agency officials realized that if they did not continue to push ahead with work on the RUG-IV system, “we risk not having the MDS 3.0 ready by Oct. 1,” she added. “If we did that, we would also not be in compliance with the legislation.”

Congress put the agency in a Catch-22 situation, and that's caused confusion in many ways, Lambowitz noted.

“I've seen all kind of advertisements and e-mails saying ‘Buy my service' and ‘Buy my product because RUGs-IV is coming at you in October.' It's almost as if they're saying CMS has no intention of complying with the law. That's not true.”

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