Caryn Adams

I am not sure our facility is receiving optimal reimbursement under Patient Drive Payment Model provisions. Where should I start?

The Patient Driven Payment Model has been in place for about six months. If you have not completed an in-depth check on how things are going, there is no better time than the present to do so. 

The facility needs to evaluate its reimbursement. Is it higher or lower than expected? If so, complete an analysis to understand why. Remember: The types of clients served most likely did not change. 

Start with the ICD-10 coding. Are the codes mapping where you would expect? Are all diagnoses that will impact reimbursement being captured on the MDS in section I? The MDS is what is driving the payment. 

Complete an MDS accuracy audit to ensure everything is captured and that everything coded on the MDS can be supported with documentation from the Medical record.

Now also is the time to review the therapy reimbursement and contracts again. Are the payments to contract therapy companies in line with what was anticipated? Are the payment arrangements with the therapy company working for both the facility and the therapy company? The agreement should be fair and equitable. 

If there are areas you are concerned about, bring in a consultant to assist. They can review the coding and MDS for accuracy and provide education to improve systems and processes which ultimately will improve compliance and reimbursement. The other area to focus on is documentation. Does it support skill? Does it reflect the primary diagnosis and support medical necessity for the Medicare stay? These are all areas that would fold in nicely to the facility’s QAPI program.