Ask the Payment Expert about ... keeping finances in order for 2017

Ask the payment expert ... about the observation stay loophole
Ask the payment expert ... about the observation stay loophole

With the first month of 2017 already behind us, what are some recommendations to keep your “financial house in order” the rest of the year?

Accuracy of the MDS will assist you in making sure you are getting the correct reimbursement for Medicare, and in many states, Medicaid. Of course, you need to continue ensuring that documentation is present in your medical record to support what you code. 

A second area related to the MDS is calculations of Quality Measures. Make sure you are monitoring your QMs on a monthly basis and putting corrective action plans into place for any not in the proper range.

Remember that the SNF Value Based Purchasing program is already collecting data from your MDSs and claims to determine your incentive payment for the future. A couple of ways that you can continue to monitor your compliance are through the Program for Evaluating Payment Patterns Electronic Report (PEPPER) reports and by understanding findings from the ADR process and responses.

The PEPPER reports are published in April each year and are next anticipated by April 17, 2017. They  will evaluate how you compare to others related to the ADL scoring, levels of therapy, Change of Therapy (COTs) and  long episodes of care.  If you are scoring above the 80th percentile or below the 20th percentile, you need to determine why and be prepared for scrutiny. Additional Development Requests (ADRs) and other medical reviews are an ongoing process that is used by CMS to recoup dollars from facilities. 

We are seeing larger numbers of medical reviews as CMS continues to tighten its dollars. One of the main areas of denials is medical necessity of care. This typically means that CMS is not seeing adequate documentation to support the level of care provided.