Has a day gone by when you haven’t heard about a new healthcare reform requirement coming of age? This month skilled nursing facilities were supposed to have started having an operational compliance and ethics program in place. Serious stuff. But don’t despair: Chances are, you have most of this in place already!

The new programs are to be effective in preventing and detecting criminal, civil and administrative violations and promote quality of care consistent with regulations developed by the Secretary of the Department of Health and Human Services, working jointly with the agency’s Office of Inspector General.

In one way, providers have been granted a bit of a reprieve since HHS spokesmen have said that the mandate would not be enforced until a final rule spelling out exactly what providers are supposed to do is issued. That doesn’t mean providers can simply shrug off the ultimate mandate.

Compliance programs are not new to the nursing home industry. Over the last 12 years, we’ve taken “baby steps” towards this requirement. While we were learning to walk, the OIG’s language has grown up too; transition from “may have” to the current “must have” for SNFs.

Now work with me on this one. The MDS is pretty much the industry driver. The MDS is how you deliver care, get paid and are judged. Do you know if your MDSs are coded accurately to consistently support Medicare and Medicaid billing? Most people believe that the MDS coordinator is always “on top” of her game or that their EHR data scrubber covers this.  However, ongoing changes to reimbursement with the implementation of RUG-IV and the unscheduled MDS assessment system could play havoc with your internal systems, jeopardizing your organizations compliance.

MDS data integrity is the heart and soul of accurate reimbursement, and an essential component of a well-functioning compliance program. Compliance issues may arise from external groups probing data in certain patterns. MDS assessments related to high therapy minutes and low ADL scores — unlikely MDS combinations or sequences, and missed opportunities for residents with chronic, debilitating diseases that may need maintenance therapy services to stay at their current functioning level (access to care) — may be targets for compliance and all rely upon MDS coordinator knowledge of coding completion and scheduling techniques.

Case in point: not applying the “change of therapy” (COT) day count correctly can easily jeopardize the facility’s reimbursement. This, in turn, could potentially impact multiple payment systems that could result in provider liability for payment.

Ask: Do you know how many COT OMRA assessments your organization performs per month? Do you have systems in place to look at the need for COT assessments, in daily operations, and prior to month-end close?

Systems that are designed to detect and prevent administrative violations are one component of the compliance regulations. We investigated this and here is what we found:


Does your average number of COTs qualify you as an “outlier”? How can these pitfalls be avoided? Make use of the seven-day encoding period provided prior to submission to conduct internal audits to ensure that each MDS is coded accurately prior to submission.

Detection can take many forms but should include an element that targets MDS accuracy, and looks at unexpected outliers in your data — and provides review prior to billing as part of your billing process. Another common approach is the triple-check process that reviews MDS items, billing items and medical record documentation to confirm consistency across the systems, and should be completed for every MDS coded for Medicare payment. When the triple-check process is done correctly, many payment issues are avoided.

Lastly, a review of therapy documentation and corresponding MDS assessments should be conducted to ensure that RUG levels remain stable, or the appropriate COT OMRA assessments are completed.

The OIG, RAC and MAC auditors, Fiscal Intermediaries and many other groups have their eye on the MDS. Beat them to the punch! Tighten up your MDS data accuracy through constant vigilance. Whether you use an automated program for data accuracy or have a manual process in place, don’t wait for the external scrutiny spurred on by pending compliance regulations in the form of a RAC, MAC, MIC or other scrutiny to identify potential compliance issues with your MDS coding process.

Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc