Is Your Revenue At Risk With The New MDS?

To be frank, the implementation of the Minimum Data Set (MDS) 3.0 version 1.18.11 assessment did not go as smoothly as most had hoped. Even the most prepared providers could not have anticipated stumbling through continuous electronic medical record (EMR) glitches, overlapping with twenty-one (21) errors in the MDS RAI Manual version 1.18.11 identified by the Centers for Medicare and Medicaid Services (CMS), and issues submitting MDS assessments into Internet Quality Improvement & Evaluation System (iQIES).

How Did Errors Impact Providers?
EMR errors were not specific to any one vendor, CMS said all EMR vendors experienced problems. To illustrate the magnitude and complexity of errors providers encountered; one-month post-implementation of the MDS 3.0 version 1.18.11, one of the most prominent EMR software’s in the US continues to investigate unresolved errors, releasing a multi-page document detailing the status of resolutions. So, what’s going on? Across multiple software vendors, providers reported significant complications:

  • Health Insurance Prospective Payment System (HIPPS) scores were not calculating for OBRA assessments
  • Incorrect HIPPS scores were calculated for MDS assessments for Medicare
  • Erroneous skip patterns resulting from both CMS technical errors and EMR technical errors
  • Not able to obtain Resource Utilization Groups (RUGs) scores
  • Received inaccurate Patient Driven Payment Model (PDPM) scores
  • Section GG calculation errors
  • Unable to submit MDS assessments
  • Software patches were issued after the fact, and are not consistently updated

What Does This Mean for SNF Revenue?

As SNFs begin billing for claims under the MDS 3.0 v 1.18.11, administrators should be aware how EMR glitches may impact their revenue. Inaccurate clinical reimbursement (PDPM/RUGs) scores auto populated in EMRs put SNFs at risk to submit incorrect claims. SNFs across the country have reported various components of reimbursement have not calculated, or not fully been captured, by their EMR software. This could leave valuable dollars on the table for skilled services already provided.

It is recommended SNFs develop a triple check-type system to verify PDPM and/or case mix scores prior to billing. Modifications and adjustments to both MDS assessments and claims should be expected based on the ongoing corrections to the errors identified through either CMS or software vendors.

Typically, IDT members use reports created by their EMR to guide Triple Check. With the current situation surrounding EMR errors post- MDS v 1.18.11 implementation, these reports should be considered unreliable. SNF IDT members participating in the Triple Check meeting should use their acute understanding of how each case mix adjusted component under PDPM – Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing – is calculated, to verify accuracy of claims for payment.

Providers should plan to suspend use of EMR reports for Triple Check meetings for October 2023 and November 2023 claims.

Three tips administrators can use for Triple Check meetings:

  • For MDS’s completed before 10/1/2023, download prior period reports from EMR software. Unless a new Interim Payment Assessment (IPA) MDS was completed, providers can use prior period reports to verify that the HIPPS score or Patient Driven Payment Model (PDPM) score remains the same.
  • For MDS’s completed on or after 10/1/2023, confirm the accuracy of each case mix group.
  • SNFs located in states approaching a case mix freeze should review and optimize Medicaid case mix index (CMI) scores; determine if any residents need an MDS completed prior to the cutoff date.

How Can We Help?

Celtic Consulting, a post-acute advisory firm, provides operational, clinical, and financial support to health care providers. Celtic has partnered with SNFs for over twenty years; guiding facility teams through many changes impacting reimbursement, regulatory compliance, operations, and accuracy. Our associates work collaboratively with clients; developing a plan to successfully adapt your operations to meet new MDS requirements. The firm frequently partners with SNF IDTs to provide advisory support for Triple Check meetings and provide MDS reviews for accuracy prior to submission and billing.

Contact Celtic today, let’s discuss how we can assist your organization.

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