Most audits are conducted in very similar manners. They also determine their focus using very similar techniques. Recovery Audit Contractors (RAC) are announcing their focus for complex reviews on their websites. The main difference between them is what they are specifically looking for. These examples are taken from various real-life scenarios and potential scenarios.
Editor’s note: Why isn’t revenue cycle management (RCM) practiced more often in long-term care? It not only requires an investment in an environment with many competing priorities, limited resources, and staff who are tasked with wearing multiple hats, but also involves getting buy-in from staff and senior leadership, which can be a struggle. With the proposed prospective payment system reform--which shifts the focus from time spent on providing services to a whole-resident approach--and CMS’ increased efforts to take back overpayments made by Medicare, it’s become increasingly evident that revenue integrity impacts all departments, not just billers.
Payroll-Based Journal (PBJ) data submitted to the Centers for Medicare & Medicaid Services (CMS) in accordance with the agency’s requirement that went into effect July 1, 2017, is now live on Nursing Home Compare and is being used to calculate the staffing rating in the Nursing Home Five-Star Quality Rating System. Beginning June 1, 2018, CMS will no longer collect facility staffing data through the CMS-671 form, meaning that providers will no longer have to fill out page 2 of this form.
With the release of the proposed rule on April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) introduced the Patient-Driven Payment Model (PDPM) with a proposed implementation date of October 1, 2019. This model is intended to replace the current prospective payment system reimbursement structure, Resource Utilization Groups, Version IV (RUG-IV), and significantly revises the Resident Classification System, Version I (RCS-I), which was introduced to the industry as a proposed RUG-IV replacement in an Advanced Notice of Proposed Rule Making (ANPRM) in 2017. RCS-I and PDPM were developed in conjunction with Acumen, a consulting group hired by CMS, and an interdisciplinary technical expert panel.
Due to the complex nature of managed care (MC) insurance as compared to traditional Medicare, staff education and training in these types of admissions can be difficult. For one, it’s easier to find information on requirements for traditional Medicare because it’s more uniform than the various managed care plans, which each have their own rules and criteria for payment. For another, MC plans require referrals for provider services, meaning that the facility must verify what prior approvals are needed before services are rendered to ensure payment.