Editor’s Note: This article has been updated from its original version, to link to a more recently revised version of the Medicare Benefit Policy Manual.

Skilled nursing providers should ratchet up Medicare Part A compliance initiatives to meet the increasingly intense scrutiny of the Centers for Medicare & Medicaid Services, a compliance expert said in a McKnight’s Super Tuesday webcast.

“CMS is serious about this. They’re returning significant amounts of payments to the program due to issues with compliance and documentation processes,” said Leah Klusch, executive director of The Alliance Training Center. “You have to be just as serious. The rules are not rocket science. You need to make sure the MDS’s and bills match, and people delivering care know definitions.”

CMS has turned to computer technology through its Fraud Prevention System, using a sophisticated analytical program that has already helped identify more than 500 providers that will face increased oversight through the new ZPIC audit system, Klusch noted.

She encouraged providers to rely on technology, as well, by using “scrubbers” that generate electronic comparisons of Minimum Data Set and billing data, to ensure consistent data. It’s been “fairly easy” to find inconsistencies in the federal database between billing and the clinical record, according to Klusch. Inconsistencies in fields such as admission diagnosis and types of service can lead to “intense audit activity,” she cautioned. For this reason, using a computer program to check for consistency is preferable to a triple-check manual process.

Admission primary diagnosis in particular is being scrutinized very closely by CMS right now, Klusch noted. In addition to briefing staff to ensure compliance around admission, Klusch advised evaluating utilization review activity. The minutes of utilization review meetings should spell out whether the resident will continue under Part A coverage or be transitioned off it. Review audit contractors and ZPICs often ask to review these minutes, so they should be easily retrievable and filed in chronological order. 

With regard to knowing definitions of care covered under Part A, Klusch advised having up-to-date compliance manuals available to staff. These include Chapter 8 of the Medicare Benefit Policy Manual and the MDS 3.0 Quality Measures User’s Manual. Click here for the MBPM. Click here for the Quality Measures manual.

The full webcast is available for viewing in archive at mcknights.com/expo2013