Indiana Medicaid Reimbursement Update Tysen Adams, CPA Deborah Lake, RN, RAC-CT Senior Managing Consultants BKD, LLP

Transcription

1 Indiana Medicaid Reimbursement Update Tysen Adams, CPA Deborah Lake, RN, RAC-CT Senior Managing Consultants BKD, LLP Agenda 5 To 8 Year Long-Term Care Plan Value Based Purchasing Issues Proposed Report Card Score Changes Compliance Reviews Intergovernmental Transfers/Upper Payment Limits Transition to RUGS IV 48 Grouper Strategies Indiana Case-Mix Level of Care Audits Special Care Unit 2 5 to 8 Year Long-Term Care Plan State is in discussions with Indiana Health Care Associations for a 5 to 8 year plan to modify Long- Term Care Possible reimbursement changes Continued shift to Home & Community-Based Services (HCBS) Review of entire process from Admission to Discharge Setting up Work Groups to discuss issues in more detail 3 1

2 Value Based Purchasing (VBP) Issues Clinical Expert Panel (CEP) to reconvene Includes 18 members Health Care Association representatives, OMPP, State Department of Health, Myers & Stauffer & Education Develop Phase III of the Nursing Home VBP Program Determine if satisfaction survey data will be incorporated into the Quality Add-On Determine if Quality Indicators will be incorporated into the Quality Add-On Proposed changes to report card score 4 Proposed Report Card Score Changes Proposed Revised System Simplified Scoring System Higher score reflects better performance All surveys and tags will be included More current revised system would be current through the biweekly update of the consumer reports and would include all surveys going back 30 months 5 Proposed Report Card Score Changes Revised scoring system Score is a rolling score based on all surveys in past 30 months Scoring is based on severity level Substantial compliance: 0 points No actual harm: 3 deduction points Actual harm: 20 deduction points Immediate jeopardy: 25 deduction points Maximum (best) score is 300 points 6 2

3 Compliance Reviews Myers and Stauffer recently posted an announcement to their website addressing compliance review requests Marked increase in the number of providers failing to submit requested records prior to fieldwork Failure to comply with records request in a timely manner could result in the following: Payment denials Termination of provider agreement 7 Compliance Reviews Additional requests for non-state government owned/operated (NSGO) nursing facilities participating in the Upper Payment Limit (UPL) program Bank statements for the applicable period showing that UPL funding was deposited into the operating account of the nursing facility Written policy detailing procedures for handling UPL payments Bank statements and supporting documentation for the applicable period for the check requests showing that IGT payments are made by the NSGO entity NSGO entity audited financial statements 8 Intergovernmental Transfer (IGT)/Upper Payment Limit (UPL) As of March 31, 2015, there were 394 nursing facilities in the IGT/UPL Program 25 County Hospitals now own nursing facilities in the Program $ was the average facility-specific UPL amount last quarter 9 3

4 Upper Payment Limit The April 1, 2015 through June 30, 2015 quarterly UPL payment is currently being finalized and notification letters should be mailed to the County Hospitals in the near future 10 Upper Payment Limit Calculations Partnership with a county hospital UPL = Monetary difference between the Medicare rate that would have been paid if the resident had been covered less the facility s Medicaid rate for the time period 11 Upper Payment Limit Calculations Identifies all Medicaid residents on the last day of the quarter from the Time Weighted Report (TWR) March 31 June 30 September 30 December 31 Uses latest OBRA assessment Converts the RUGS-III scores from the TWR to the RUGS-IV (66 grouper) Low Need scores do not impact 12 4

5 8 Major RUG-IV Classifications Rehab Plus Extensive Services Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms and Cognitive Performance Reduced Physical Function Strategies for IGT/UPL Remember your strategies for RUGS-III Know the differences between RUGS-III and RUGS-IV categories Components Index maximizing ADL scores and end-splits End-splits for depression and restorative Be aware of snap-shot dates and timing of assessments March 31 June 30 September 30 December 31 Strategies for IGT/UPL Capture isolation as appropriate Assess COPD residents for shortness of breath when lying down during reference periods Respiratory failure and oxygen Alter Physician Order/Visit log to reflect insulin order changes Monitor ADL s Parkinson Disease residents and ADL documentation 15 5

6 Strategies for IGT/UPL Plan therapy minutes and days of treatment 5 days and 150 minutes = RM Remember distinct day requirement for RM and RL 16 Effective July 1, 2016 Indiana Nursing Facility rates will be calculated using RUGs IV 48 grouper For a one year period Further extension depends on discussion and progress on 5-8 year plan $6.9 million more than RUGs III Unspent money from Quality Assessment Fee Therapy scores will not be re-ruged at this time Index maximizing 17 Indiana Transition to RUGs IV ADL Score Calculation ADL score 0-16 vs RUGS III range of 4-16 RUGS IV range of 0-16 RUGS IV only Most commonly coded score of 2 (Limited Assist) has been devalued Tube feeding/iv fluid component removed Weight given to staff support with feeding 6

7 RUG-III Late Loss ADLs Bed Mobility, Transfer, Toileting, & Eating RUG-IV Late Loss ADLs Bed Mobility, Transfer, Toileting, & Eating Limited vs Extensive Assistance Limited Assist (2) = Resident highly involved in activity Guided maneuvering No weight bearing Staff uses hands to guide no use of muscles No bearing of weight of any part of the resident Contact guard Physical directing of the resident Mothers gentle touch Hands on top palm down 7

8 Limited vs Extensive Assistance Extensive Assist (3) = Resident performs part of activity Staff performs a component of the ADL Hands on bottom palm up Staff provides weight bearing assistance Giving resident a boost Staff uses hands and muscles Weight bearing some or any of the resident s weight Weight bearing is determined by who is supporting the weight of the resident or extremity Extensive Services (ADL = 2-16) 48 Grouper 23 Ventilator and trach (ES3) Trach or ventilator (ES2) Isolation (ES1) Services while a resident ADL score of 0-1 classifies as Clinically Complex Isolation or Quarantine 4 criteria must be met Active infection with highly transmissible pathogen(s) Precautions over and above standard precautions (contact, droplet and/or airborne) In a room alone because of infection and cannot have a roommate Resident must remain in his/her room requires all services be brought to the resident Does not apply for UTIs, encapsulated pneumonia, wound infections 24 8

9 48-Grouper Rehab 150 minutes or more and 5 distinct days of any combination of ST, OT or PT OR 45 minutes or more and 3 distinct days of any combination of ST, PT and OP and 2 or more restorative services (6 or more days) 25 Restorative Nursing Programs Administered during 7-day look-back period Specific program must have been administered at least 15 minutes during the 24 hour period Measurable objectives and interventions outlined in a plan of care Supervision by a licensed nurse (RN or LPN) Evidence of periodic evaluation by a licensed nurse note can be written by a restorative aide and co-signed by a licensed nurse Nursing assistants/aides skilled in the techniques that promote resident involvement in the activity No more than 4 residents per supervising caregiver 26 Restorative Nursing Programs Urinary toileting program and/or bowel toileting program** Passive and/or active ROM** Bed mobility and/or walking training** Splint or brace assistance Transfer training Dressing and/or grooming Eating and/or swallowing Amputation/prosthesis care Communication training **Count as one service 27 9

10 48 Grouper Rehab ADL Dependent RAA = 0-1 RAB = 2-5 RAC = 6-10 RAD = RAE = RUGS IV 48 Grouper Rehab 29 RUGS III Rehab 30 10

11 Special Care High ADL Score 2-16 ADL Score 0-1 = Clinically Complex HE2 (15-16) HE1 (15-16) HD2 (11-14) HD1 (11-14) HC2 (6-10) HC1 (6-10) HB2 (2-5) HB1 (2-5) Quadriplegia ADL>5 Fever + Pneumonia, Feeding Tube, Vomiting OR Weight Loss Respiratory Therapy x 7 Days Coma / ADL Dependent Septicemia DM / INSULIN Injections x7 days / 2 days INSULIN order changes COPD and SOB when flat Parenteral IV feedings or fluids Special Care Low ADL Score 2-16 ADL Score 0-1 = Clinically Complex LE2 (15-16) LE1 (15-16) LD2 (11-14) LD1 (11-14) LC2 (6-10) LC1 (6-10) LB2 (2-5) LB1 (2-5) Cerebral Palsy ADL>5 Multiple Sclerosis ADL>5 Ulcers * (See next slide) Radiation While a resident Feeding Tube with intake requirement Foot Infections / Open Foot Lesions with dressings Diabetic Foot Ulcer with dressings Dialysis while a resident Parkinson s ADL > 5 Respiratory Failure and O2 Special Care Low - Ulcers Ulcer Combinations 2 or more stage 2 pressure ulcers Any # stage 3 or 4 pressure ulcer 2 or more venous/arterial ulcers 1 stage 2 pressure ulcer and 1 venous/arterial ulcer Treatments 2 or more Pressure relieving chair and/or bed ** Turning/repositioning Nutrition or hydration intervention Ulcer care Application of dressings (not to feet) Application of ointments (not to feet) ***Count as one treatment even if both provided 11

12 Special Care High and Low (ADL = 2-16) 48 Grouper Use of depressive end-split U Use of 34 Special Care RUGS III 35 Considerations: Special Care High COPD and SOB when lying down Diabetes with insulin injections (7 days) and 2 or more days of insulin order changes Parenteral/ IV feedings (Extensive Service RUG III) Special Care Low Dialysis (Clinically Complex in RUGS III) Parkinson s Disease with ADL of at least 5 Respiratory failure and oxygen administration Foot infection (Clinically Complex in RUGS III) 36 Feeding Tubes (Clinically Complex in RUGS III) 12

13 Clinically Complex CE2 (15-16) CE1 (15-16) CD2 (11-14) CD1 (11-14) CC2 (6-10) CC1 (6-10) CB2 (2-5) CB1 (2-5) CA2 (0-1) CA1 (0-1) Burns 2 nd or 3 rd Degree Pneumonia Hemiplegia ADL>5 Oxygen (while a resident) Chemotherapy (while a resident) Transfusions (while a resident) Surgical wounds / open lesions with treatment Surgical Wound Care Application of dressing (not to feet) Application of ointments (not to feet) IV Medications (while a resident) Clinically Complex 48 Grouper 38 Clinically Complex RUGS III 39 13

14 Considerations for Clinically Complex Surgical wounds and open lesions with skin treatments (Special Care with RUGS III) IV medications (Extensive Service with RUGS III) Dehydration and Internal Bleeding eliminated Physician orders/visits eliminated 40 Behavior Symptoms and Cognitive Performance BB2 (2-5) BB1 (2-5) BA2 (0-1) BA1 (0-1) Impaired Cognition and Behavior RUG categories combined removal of 4 categories Uses the Restorative End Split Cognition scores based on MDS interview BIMS or CPS Behavior symptoms defined by MDS 3.0 definitions ADL Score 0-5 Behavior Symptoms and Cognitive Performance ADL score = 5 or less Cognitive Interview BIMS <=9 Staff Observation - Difficulty in making self understood, Short Term memory or decision making (CPS >=3) Hallucinations Delusions Coded 2 or 3 (4-6 days or daily) Physical behavioral symptoms toward others Verbal behavioral symptoms toward others Other behavioral symptoms Rejection of care Wandering 14

15 Behavior Symptoms and Cognitive Performance 48 Grouper 43 Impaired Cognition and Behavior Problems RUGS III 44 Reduced Physical Function PE2 (15-16) PE1 (15-16) PD2 (11-14) PD1 (11-14) PC2 (6-10) PC1 (6-10) PB2 (2-5) PB1 (2-5) PA2 (0-1) PA1 (0-1) Needs are primarily ADL support and general supervision Uses Restorative End-Split 15

16 Reduced Physical Function (ADL = 0-16) 48 Grouper 46 Reduced Physical Functioning RUGS III 47 RUGS IV Additions/Deletions Added Conditions: Parkinson s Disease COPD and SOB while lying flat Respiratory failure with oxygen use O2 Isolation for active infectious diseases Removed: Aphasia with tube feedings Dehydration Internal bleeding Suctioning Physician orders and visits 16

17 Moved: IV/Parenteral Feedings to Special Care High IV medications to Clinically Complex Comatose to Special Care High Septicemia to Special Care High DM with both daily insulin injections and 2 days of insulin order changes to Special Care High Tube feeding alone will be Special Care Low Tube feeding with fever will be Special Care High Dialysis moved to Special Care Low Foot infection moved to Special Care Low Surgical wounds to Clinically Complex Pressure, arterial or venous wounds to Special Care Low Indiana Transition to RUGs IV Low Need Days Medicaid residents only New admission to any Medicaid-certified after January 1, 2010 Cognitive status indicated by a BIMS score greater than or equal to 10 or cognitive performance score (CPS) of 0-2 Not experiencing occasional, frequent or complete bowel incontinence 50 Indiana Transition to RUGs IV Low Need Days CMI Values: PA1 = 0.19 PA2 = 0.21 PB1 = 0.28 PB2 =

18 Indiana Transition to RUGs IV BC2 or Delinquent Days For Medicaid purposes only assessments are good for 113 days after which BC2 days will be assigned With the 48 Grouper this new value will be reduced from 0.50 to 0.45 Residents discharging prior to completion of Admission Assessment LC2 Discharge d/t death or transfer to hospital RAB Discharge other than to death or hospital transfer 52 Strategies for Indiana RUGS IV Start learning differences between RUGS III and RUGS IV 48 groupers CMI point differences Know current RUG category before scheduling new assessment End of year conversion Therapy remember distinct day requirement 53 Strategies for Indiana RUGS IV Activities of Daily Living Train, Train and Train again Limited vs. Extensive assist Monitor during assessment periods Observe care being given on the nursing units ADL Minimum Required Quadriplegia, Cerebral Palsy, Multiple Sclerosis, Parkinson s Disease and Hemiplegia 54 Extensive Services and Special Care High and Low 18

19 Strategies for Indiana RUGS IV Physician order logs Insulin dependent diabetics Insulin order changes Skin Conditions Stage 1 ulcers will not enter in RUG score 2 or more Stage II ulcers Stage 3, 4 or unstageable due to slough or eschar 2 or more venous/arterial ulcers 55 Stage II plus one venous/arterial ulcer Strategies for Indiana RUGS IV Assess COPD residents for ability to breathe while lying flat during assessment periods Diagnosis of Parkinson s Disease with medication Capture isolation as appropriate Documentation of respiratory therapy services and maintenance of staff training records 56 Strategies for Indiana RUGS IV Review hospital records In-house services IV/Parenteral fluids or feedings in 7-day look back Require services to be rendered in-house Respiratory failure with oxygen Radiation therapy, Dialysis, Transfusions Chemotherapy Oxygen IV medications Tracheostomy care, ventilator/respirator Isolation 57 19

20 Strategies for Indiana RUGS IV Ensure baseline temperatures are obtained and maintained Pneumonia, vomiting, weight loss, feeding tube Monitor physician orders and 24-hour reports for changes in condition or clinical services Review RUGS IV 48 Grouper reports on Myers and Stauffer portal 58 Strategies for Indiana RUGS IV RUGS III RUGS IV 48 Grouper 59 Strategies for Indiana RUGS IV RUGS III RUGS IV 48 Grouper 60 20

21 Myers and Stauffer Training 61 Special Care Unit Add-on MDS Items Medicaid payer (A0700) Room number (A1300B) Diagnosis of Alzheimer s Disease (I4200) or Non- Alzheimer s Dementia (I4800) Special Considerations Medicare Transfer on to unit Modifications 62 Indiana Case-Mix Level of Care Audits Responsibility for audits was assumed by Myers and Stauffer (M&S) effective July 1, 2015 New policies listed on M&S site Health Record Policy Excessive Wait Time for Medical Records Facility Request for Review Cancellation Medical Record Correction Policy Only original medical records will be accepted for supporting documentation 63 21

22 Indiana Case-Mix Level of Care Audits 64 Indiana Case-Mix Level of Care Audits 65 Item Set Changes for October 1, 2015 MDS 3.0 Item Set Change Version with a effective date C1300 Revised footnote Adapted from Confusion Assessment Method. 1988, 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission. All rights reserved

23 THANK YOU!!! 23