Medicare Compliance & Reimbursement

Nursing homes will need to be proactive to dodge losses -- and even realize big gains.

A visit from the Data Assessment Verification Project team may be enough to make even the coolest long-term care provider sweat, but consider this: In the long run DAVE may have a positive impact on reimbursement -- to the tune of $200,000 or more in a single quarter.

"It's a wake-up call," offers Leah Klusch, nurse consultant and executive director of The Alliance Training Center in Alliance, OH. Ever since the Centers for Medicare & Medicaid Services began piloting its now national initiative to ferret out discrepancies in minimum data set (MDS) data, nursing homes have been concerned that the mistakes discovered would weigh in CMS'favor. ADAVE-discovered mistake in Section P, for example, could lead a fiscal intermediary to invalidate a claim already paid for therapy services -- and to seek recoupment.

Good news: Such concerns are valid, experts agree, but providers should also see DAVE's better side, say Klusch and others. In many facilities, lack of coordination, poor communication and inadequate training all undermine administrators'efforts to secure appropriate reimbursement.

Here are some ways SNFs can make the DAVE spotlight work for them:

1. Face the facts. DAVE teams across the nation started visiting facilities May 1, reports a spokesperson for CMS. All in all, the teams plan to visit 88 facilities between now and the end of the year. Off-site surveys, which commenced in February, will also continue.

"We're just hearing the first reports of on-site visits," reports Rita Roedel, clinical operations consultant with BDO/Heritage Healthcare Group in Milwaukee. The lesson learned from these early reports: Preparation is key.

Without preparation, SNFs could find themselves in the recent position of one facility. That provider was selected in early May for on-site review - and failed to realize at first that they'd received a request for information prior to review. This kind of oversight is easy to make, allows CMS. Typically, a provider will be notified of a pending visit just a few days before the team walks in with their clipboards.

Though the prospect of an on-site inspection may be the one that leaves providers sleepless, it's not the only reason to take stock of MDS, remind the experts. Afiscal intermediary can ask for money back for a claim deemed invalid just as easily from an off-site survey. And -- even more importantly -- if a facility's MDS coordinator and clinicians aren't communicating, the facility could already be losing money through assessments that fail to capture residents'real needs, stresses Klusch.

Moneymaker: One provider that's stepped up MDS training and processes realized a remarkable $200,000 increase in reimbursement in just one quarter. "Most facilities aren't even asking for the reimbursement their case mix warrants," contends Klusch.

Another vital reason to take the steps now to audit your own MDS: If the feds do find discrepancies during an off- or on-site inspection, the SNF could be in for double trouble. In states where the MDS is used for Medicaid reimbursement, the state could be the next in line seeking recoupment of claims paid.

2. Know the hot spots. Experts advise extra caution on these MDS sections including G (physical functioning and structural problems) and P(special treatments and procedures).

Trouble spots in G: ADLs coded to reflect better than actual performance and not using the full look-back period.

Quick fix: If a SNF isn't in a state that mandates the use of ADLflow sheets -- and it's not using them on its own -- it needs to get moving. By using them, and most importantly making them a part of each resident's permanent medical record, SNFs may save themselves from losing big dollars to the feds.

"Many providers fail to pick up when the resident is most dependent," suggests Pat Boyer, operations consultant with BDO/Heritage Healthcare Group. By using a flow sheet to support and document assessments, coders can more easily assure a true picture of a resident's performance over a full 24-hours.

In Section P, red flag therapy-related items. If a SNF miscalculates rehab minutes or codes nursing rehab/restorative care that doesn't meet CMS'criteria, it could find itself holding a fiscal intermediary's request for claim repayment.

"It is just mathematics, but many can't seem to get it right," explains Boyer.

Quick fix: SNFs should always reconcile minutes on therapy logs with the MDS. If they contract for therapy services, they must take two additional steps: Check their contract for an indemnification clause, and be sure that therapists sign the MDS, Roedel says. "It's the only way you can really hold them liable for MDS accuracy."

Catch a mistake? If a SNF notices that a claim that's been paid had the wrong number of minutes in Section P, the best course of action is to submit an adjustment bill to reflect corrections to the MDS data that result in changes to the RUG code. One caution: Facilities should remember that the correction is not a new assessment and cannot be used as a replacement for the next regular Medicare assessment. Also, it must document the reason for the correction and keep it in the medical record.

Be informed: Providers who have general questions about DAVE may call 800-561-9812. For an outline of other common problems, go to www.cms.hhs.gov/providers/psc/dave/homepage.asp.

If your questions about DAVE relate to a request for medical records, call 800-533-8894.