Here are three recent situations that show how Roush & Associates' customized reimbursement-maximization solutions have helped clients significantly increase their revenues.

Case 1: Understanding the MMQ Process
Case 2: Interim MMQ Services Pay Off
Case 3: MDS Training Improves Medicare Reimbursement Rates
Case 4: Audit Identifies Revenue Opportunities

Reimbursement-Maximization Strategies: How They Can Work for You

While healthcare today is still first and foremost about delivering quality care, financial viability in the post-acute and longterm care segments of the business is increasingly dependent on paperwork. Understand the subtleties of Medicare and Medicaid patient-assessment forms and the supporting documentation required, and you receive the maximum reimbursement available for each resident's care. Miss the finer points or fail to sufficiently back up your observations, and you've made a costly mistake.

In a healthcare environment where every payer is looking to minimize costs, having a reimbursement-maximization strategy is key to the survivability of most skilled-nursing facilities. What does this involve? First, an in-depth understanding of the paperwork and processes used by government payers to determine reimbursement rates. Second, policies and procedures that direct caregivers to appropriately document the actual care provided to each resident.

UNDERSTANDING THE PATIENT-ASSESSMENT PROCESS

Both Medicare and Medicaid have patient-assessment tools, the results of which set the reimbursement rate you receive for each resident.

MAXIMIZING MEDICARE-Medicare uses the MDS (Minimum Data Set) tool nationally. There are two aspects of the MDS that are particularly important for maximizing reimbursement:

• Section G, where the ADL (activities of daily living) index is established. If the ADL index under-reflects the amount of care the resident needs, then the RUGS category will too-and your reimbursement rate will be lower than it could be.
• The assessment reference date. Many facilities set the date automatically-a big mistake. Our experience indicates that it's well worth the effort to learn the ins and outs of date-setting and to do so on a case-by-case basis, to capture the highest appropriate category designation.

MAXIMIZING MEDICAID-Medicaid is a bit more complex because each state develops its own patient-assessment tool. Nevertheless, the concepts behind each are similar:

• Massachusetts uses the Management Minutes Questionnaire (MMQ), a one-page document that's completed based on information from resident records. Through this process, the MMQ nurse determines the total minutes of care per day that a resident requires. The score at the questionnaire's end determines the reimbursement category for that resident. Assessments are done quarterly, but residents aren't assessed until they convert to Medicaid.
• New York uses the Patient Review Instrument (PRI), a four-page document that, like the Massachusetts process, results in a score that is tied to a reimbursement category. In New York, a PRI must be completed for every person in a long-term care facility, regardless of payer source. New admissions are assessed during the quarter of admission, and the full house is assessed every six months.
  

DOCUMENTATION, DOCUMENTATION, DOCUMENTATION

It's not enough just to provide quality care today. You have to document it-accurately-to receive the greatest reimbursement possible for the services you provide. Not only does documentation need to be thorough and accurate, it must reflect continuity and consistency from month to month, illustrating appropriate care responsive to a resident's medical status. Today, rigorous documentation is essential to successfully complete an audit.

HOW ROUSH & ASSOCIATES CAN HELP

Roush & Associates can be part of your reimbursement-maximization solution in several ways, depending on your facility's needs. We provide a full range of ongoing reimbursement-maximization services, we can train and coach someone on your staff, or we can provide interim services when your trained staff member leaves.

One particular advantage of our solution: Our reimbursement-maximization consultants are all licensed nurses. Our clinical professionals talk to yours-nurse to nurse.

There is, of course, some variation from month to month in what you can achieve through reimbursement-maximization strategies, based on your patient mix at the time. The key is to realize your full reimbursement potential each month.

To find out more about our reimbursement-maximization services, call Roush & Associates at 781-213-9099.

Reimbursement-Maximization - Cases in Point

Here are three recent situations that show how Roush & Associates' customized reimbursement-maximization solutions have helped clients significantly increase their revenues.

Case Studies

Case 1: Understanding the MMQ Process

The Client
A 120-bed skilled-nursing facility in Western Massachusetts.

The Situation
In the previous quarter's audit, this facility experienced a retroactive reduction in reimbursement.

The Solution
Our reimbursement-maximization expert, Deborah Paine-Motyl, RNC, conducted an on-site audit of the client's MMQ process. She found that the MMQ nurse was making errors that cost the facility reimbursement dollars, and the documentation by caregivers did not adequately describe or support the services being provided. Deb coached the staff on documentation techniques and assessed the skill set of the MMQ nurse for management.

The Results
At a subsequent MMQ audit, our client's reimbursement rate did not merely return to its previous level, but exceeded it. Our expertise increased this client's reimbursement rate by approximately $7.50 per patient day for the quarter.

Case 2: Interim MMQ Services Pay Off

The Client
A 140-bed skilled-nursing facility in Central Massachusetts.

The Situation
This facility was without a qualified MMQ nurse.

The Solution
Roush & Associates stepped in. We prepared this client's quarterly assessments and reviewed resident records to ensure that there were several months of solid documentation to back up those assessments.

The Results
These efforts yielded this client an average increase of $6 per patient day.

Case 3: MDS Training Improves Medicare Reimbursement Rates

The Client
A 140-bed skilled-nursing facility in Central Massachusetts.

The Situation
To further maximize reimbursement, this facility asked us to review its MDS procedures and determine areas for improvement.

The Solution
We discovered that this client was missing opportunities for Medicare reimbursement in two areas: accurate coding at Section G, establishing the ADL index, which drives RUGS categorization; and setting assessment reference dates. Both areas were addressed through intensive staff training.

The Results
Staff members' expanded understanding of the nuances of the MDS process resulted in a significant increase in revenue.

Case 4: Audit Identifies Revenue Opportunities

The Client
A 120-bed skilled nursing facility in Rhode Island.

The Situation
As part of a multi-facility firm, this health center was not achieving reimbursement levels of company counterparts. We performed a PPS audit conducted over several days.

The Solution
Quantifiable financial opportunities were identified, for example, by instituting a new CNA flow sheet that correlated directly with the MDS and by reviewing the relationship with the rehab service provider, revenue PPD could be increased between $30 to $45.

The Results
Recommended changes were made enhancing reimbursement received by the facility.