1 long Term care Issues HFMA. Healthcare Financial Management Association Thursday March 17th 2011. Los Angeles, CA. Presenter Michael Lesnick Ron Wall 714-323-5968 909-472-8900. Axiom Healthcare Group Topics Medicare RUG IV Categories Questionable Billing Practices in SNFs OIG. Report A Gaze Into the Future 3. RUG-IV Overview What Are The Thirty (30) Most Critical Things To Know About RUG-IV? 4. RUG-IV Overview What Are The Thirty (30) Most Critical Things To Know About RUG-IV? MDS , MDS , MDS , MDS MDS. , MDS , MDS , MDS , MDS MDS , MDS , MDS , MDS , MDS.
2 MDS , MDS , MDS , MDS , MDS MDS , MDS , MDS , MDS. , MDS MDS , MDS , MDS , MDS , MDS , MDS 5. RUG-IV Overview Implementation Date Originally 10-1-2011. Now Payment Under RUG-IV Effective 10-1-2010. With A Catch . Starting 10-1-10 you will be paid under the 66. category RUG-IV classification system, BUT, you will be earning the 53 category RUG-III HYBRID . rates GREAT NEWS RUG IV Delay Is Repealed! There will NOT be a RUG III Hybrid To Deal With 6. RUG-IV Adjustment to RUG-III HYBRID. Currently the only Grouper Software that will function under MDS will only produce the RUG-IV grouping In other words CMS can NOT comply with the law that mandates a RUG-III payment under the MDS Therefore, you get paid RUG-IV rates now and sometime in the coming months CMS will figure out how to take the difference between RUG-IV and RUG-III HYBRID rates back from you GREAT NEWS RUG IV Delay Is Repealed!
3 There will NOT be a RUG. III Hybrid To Deal With! Happy Holidays! President Obama has delivered the LTC. industry with a holiday gift by signing into law the Medicare and Medicaid Extenders Act of 2010. Section 202 of the MMEA repeals the delay of the Skilled Nursing Facility (SNF) PPS RUG-IV. classification system. Therefore, RUG- IV will continue to remain in effect from October 1, 2010, as previously implemented by the final SNF payment regulation for FY 2011. All claims processing activities shall proceed in accordance with the existing instructions.
4 (Big Sigh) And to All a Good Night! 7. NEW Rates Look GREAT!!!! Or Do They???????????????? If you simply compare the Old Rates (FY 10. Rates) to the New Rates (the FY 11 Rates) It looks like you will have a very significant increase. Please be aware that under MDS and the new rules about Therapy Minutes and Look Back Periods, it will be much more difficult to achieve the higher RUG categories and to get Therapy minutes recorded. Also, remember you are earning only the RUG-III. Hybrid rates that are lower than the RUG-IV rates 8.
5 Why Is It More Difficult To Get Into Various RUG Categories? Extensive Rehabilitation 9. More Difficult To Get Into Extensive Categories To date, the vast majority of the extensive qualifiers occurred in the acute care hospital before admission to the SNF. Look Back Periods will be modified to prohibit providers from taking credit for certain services (specifically the extensive qualifiers) that occur in the acute care hospital before admission to the SNF. For RUG-IV purposes, the look back period for section P1a items will NOT include any services rendered before the patient was admitted to the SNF.
6 Services prior to admission (those provided in the hospital) are still recorded, but, only for care Planning purposes, not for reimbursement purposes 10. More Difficult To Get Into Extensive Categories Qualifiers for Extensive Categories Have Changed The Number of Extensive qualifiers is reduced The Remaining Extensive qualifiers are: Existing - Tracheotomy care IN THE NURSING HOME. ONLY. Existing - Ventilator / Respirator care IN THE NURSING. HOME ONLY. NEW Isolation QUARANTINE for an active infectious disease IN THE NURSING HOME ONLY.
7 11. What Is Isolation QUARANTINE? Examples Of Conditions That Do Qualify Active Cases of TB. Neutropenic Precautions Isolation (look it up). Active Shingles (Airborne). MSRA In The Respiratory Tract with Wet Productive Cough (Airborne). Examples of Conditions That Do NOT Qualify Normal MDROs (Multi Drug Resistant Organisms). MSRA. VRE. Not What SNFs Typically Call Isolation 12. Extensive Qualifiers That Have Been Eliminated Some of the services that were formerly extensive qualifiers will be moved to other categories Parenteral / IV Feeding moves to Special care .
8 High IV Medications moves to Clinically Complex Suctioning has been dropped completely as a qualifier 13. Why Is It More Difficult To Get Into REHAB Categories? Section T Eliminated Counting Minutes Modified Concurrent Therapy Aide Time 14. Counting Rehab Minutes The manner in which Therapy minutes are counted has been modified Method Of Rehab Delivery Individual Therapy No Change Group Therapy No Change (Be Careful About Coverage Criteria). Concurrent Therapy Minutes Will be allocated /. Limited to 2 patients (1/2 of time counted for reimbursement purposes).
9 15. Counting Rehab Minutes Aide Time Is essentially limited to set up time The old practice of counting all of the aides time (for a Part-A patient) under line of sight supervision by a licensed therapist is no longer acceptable, only the setup time is counted 16. Value of Categories Has Shifted Essentially Rehab is worth less under RUG-IV. and NON-Rehab (Extensive / Medical). Conditions are worth more 17. RUG-IV Overview Impact On Rates / Payments Overall Payments to SNFs WERE expected to be Budget Neutral , with a SIGNIFICANT re- shuffling of the payments among categories.
10 There be a reshuffling, but, with the move directly to RUG IV the overall cost to the government will NOT be budget neutral. 18. RUG-IV Overview Winners & Losers In a very global sense, therapy services will be worth less and complex medical services (actually performed in the SNF) will be worth more Therapy reimbursement remains very attractive and will continue to be a major element of Medicare reimbursement. 19. RUG-IV Overview Winners & Losers SNF Most Likely to be negatively affected NOTE LOSSES ARE MITIGATED BY THE SKIP.