Medicare Compliance & Reimbursement

What SNFs' computers say about RUG categories could come back to haunt them.

Sure, a skilled nursing facility's billing office knows all about Resource Utilization Groups, but problems with the billing office computer could land the SNF in a heap of trouble with the feds.
 
Hot news: At the SNF/Long-Term Care Open Door Forum Mar. 30, Centers for Medicare & Medicaid Services officials dropped this potential bomb: They're on to the fact that certain software vendors have modified their MDS product in ways that may wind up bumping a resident up from the RUG with the highest case-mix index to the RUG with the highest payment rate.

When a resident qualifies for more than one RUG III score, the grouper software typically chooses the RUG with the highest case-mix index, explains Brian Dimit of  Keane Care Inc. in Bellevue, WA. Originally that top group coincided neatly with the top payment rate, but that all changed when the SNF prospective payment system tacked on add-on rates to compensate facilities for certain types of high-cost care. Since then, the highest case-mix index may no longer carry the highest payment rate.

To some software vendors, that shift spelled an opportunity for a little creative programming -- specifically the addition of a feature that essentially defaults to the RUG coinciding with the highest possible rate when a resident seems to fit in several groups, even though in reality that group may not be the group most appropriate, says Dimit.

Keane Care's MDS product, VistaKEANE Resident Assessment, has not modified in any way deemed inappropriate by CMS.

The bottom line: CMS has given a definite thumbs-down to a practice some software vendors may have touted as giving SNFs a financial advantage -- and CMS has vowed to follow quickly with a crackdown that could leave providers refunding overpayments.

Take A Close Look At MDS Software

To steer clear of trouble, SNFs should make sure their billing office is current on CMS' newly stated stand, stresses Diane Brown, CEO of Brown LTC Consultants in Newton, MA. If necessary, they should contact their software vendor for clarification about just how its product works.

Don't miss this: In addition to the problematic modification involving RUG reclassification, CMS also reported that some software used by nursing facilities has been modified to advise providers that completion of the MDS Section T (therapy supplement form) is optional for a five-day assessment. The word at the Open Door Forums: Section T continues to be required, even for the five-day assessment.