Ask the payment expert: will state Medicaid payments change with the switch to Medicare RUGs IV?

Share this content:
Ask the payment expert
Ask the payment expert

When the Medicare payment system changes to RUGs IV, will state Medicaid payment systems also change?

Not necessarily. In fact, I know of at least a few states that have already made the decision to stay with the present RUGs III system. With Medicaid shortfalls in many states across the country, they may be unable to spend additional dollars to make another change, so facility staff will have to manage two separate systems at the same time.

It will be essential to monitor those residents who are Medicare and Medicaid and to know what the RUGs IV level is, and at the same time, know the RUGs III level. Each will have different implications to payment. The use of the Significant Care of Status Assessment (SCSA) will become more important to your Medicaid reimbursement.

Although I.V. medications and I.V. fluids will continue to qualify for a Medicaid RUGs level of Extensive Services, the same information will qualify the Medicare resident only for Special Care or Clinically Complex.

In addition, two separate ADL coding scores will need to be calculated for those residents, as the scales for the two systems will be different. (If this seems confusing, it is. )

Today, more than any time in the past, it is essential for each facility to have a skilled MDS Coordinator who knows how to manage both systems. 

What is the benefit of having a mock survey?

Having an objective pair of eyes look at your facility and interview your residents can assist you to be successful. If you do not have corporate staff to complete a mock survey, have a sister facility, another peer group or someone you hire do it. It will be well worth your time and money.