Caryn Adams

I have received questions from multiple states on how to improve Medicaid reimbursement. Any ideas?

Medicaid reimbursement is state specific, so I cannot make global suggestions that would apply to everyone. If you are in a RUGs-based state, the focus is on increasing the case-mix index to improve reimbursement. 

There are several common areas we identify during our assessments that are lacking. MDS coding is not capturing what is supported in the documentation. Capturing the items during the look-back period that impact the case mix is essential to improving the rate, as well as completing an accurate clinical picture of the resident. Ensure MDS staff understand what those items are, and that clinical staff know where and how to document accordingly. 

Restorative nursing can significantly impact the reimbursement for those residents in the reduced physical functioning categories. Review the requirements of the program and ensure that staff is performing and documenting that the program is occurring. Restorative nursing also improves resident outcomes and successful discharges to the community.  

Also consider capturing respiratory therapy. Review the RAI guidelines and be sure that only the minutes spent with the resident are being captured. Review the process for scheduling OBRA MDS, as well as capturing significant changes. Often, we see the MDS completed, and then the referral to therapy. But starting to review residents a little further out, the therapy frequency can be captured on the MDS.

In addition, ensure that the MDS coordinator is willing to flex the ARD date to capture therapy minutes or other services, treatments and conditions that will impact the case-mix and capture the true clinical picture of the resident.