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Ask the payment expert
Ask the payment expert
We recently lost our MDS nurse and assessments are backing up.  What should we do? 

You cannot be without someone to complete your assessments. We strongly recommend that multiple people are involved in this process so that if one person leaves, your system does not come to a halt.  
From an OBRA standpoint, if your assessments are not completed promptly, you are out of compliance and you can receive a survey deficiency. From a reimbursement standpoint, the results of untimely assessments can be financially devastating.

The RAI Manual is very specific on this subject: “SNFs that fail to perform assessments timely are to be paid a RUG-III default rate for the days of a resident's care for which they are not in compliance with this schedule.”

Your MDS is the starting point of your assessment of the resident's needs and results in you developing or revising your plan of care. As a result, timeliness of the assessment process is essential.

We hear that a lot of medical review activity is occurring. Can you give us any insight into this development? 

Much of it is pre-payment random reviews. I feel that it is based on the finds of the medical review in Florida this past year when 19 of 100 claims were found not to be medically necessary.

Facilities with high RUG levels seem to be being targeted. If you have very high RUG categories (RU or RV) for more than 30 days and high levels with medical diagnoses, you need to have someone review your practices to make sure they stand up to medical necessity requirements.

Although medical review is subjective, if you do not have favorable outcomes with the focused review, you risk being placed on 100% pre-payment review. That will wreak havoc with your cash flow. Seek out assistance early in the process.