AHCA Convention in Las Vegas

 TheraStat and MDSMax will be at the AHCA Convention at Mandalay Bay in Las Vegas September 18-21! We'd love to see you so come by booth 525. We will be giving away chances to win 6 month free trials of MDSMax!

Find out why our customers are among the highest reimbursed around. (Hint: It's not because they have patients different from yours.)

We will also have kiosks set up so you can try MDSMax for yourself and see just how easy it is to use. See you there!

4 Therapy Changes, How Likely Are They?

Like the horseman of the apocolypse, CMS is trying to send us four changes to therapy. Do you know what they are and how they might affect you? Let's find out. How many of these are you familiar with?

• Reallocation of group minutes
• COT OMRA
• Parity Rates
• Medicare Part B Caps

Which of these is most likely to be implemented? Which one would have the largest effect on your business?

Let’s briefly cover each one based on what we know so far. (The details are likely to change, this is CMS remember.)

Change:  Reallocation of group minutes

What it means:

 The idea here is that CMS would like to reimburse therapy providers for 1 minute of group therapy for every 4 minutes they perform, regardless of the number of people in the group. Group therapy used to account for only a small overall percentage of therapy performed. However last October CMS cut reimbursement for concurrent therapy by 50%. Once that happened, providers switched to group therapy where appropriate as a way to keep productivity up. As of right now, virtually no one does concurrent therapy and group is on the rise, which effectively negated the cost savings that CMS expected to see.

Bottom Line:

Once the reimbursement for concurrent was cut by 50% providers stopped doing it and moved to group therapy where appropriate. If the reimbursement for group is cut by 75% then group therapy will virtually stop. This will either increase the cost of achieving the same RUG or lower the RUG utilization.

Likelihood: Very High/High

Change: Change of Therapy (COT) OMRA

What it means:

When CMS switched to a prospective payer system (PPS) it meant that they would measure the amount of therapy provided over a short period and use that to project how much therapy would be performed in the future and pay providers based on that. The only problem with that system is that unscrupulous providers could simply provide a high number of minutes during that short assessment period and then provide less or even none after the assessment. CMS would then basically be paying for therapy that will never occur. Some might argue that this is a fatal flaw for this type of system.

CMS is now proposing that if therapy does not continue at the same level that occurred during the assessment period, then a COT OMRA assessment must be done and the reimbursement adjusted accordingly. The reimbursement can be adjusted up and down, but CMS is banking on a lot more downward movement I assure you. This has been in the works for a while. Remember when therapy discharge dates appeared on MDS 3.0? Well now you know why.

Bottom Line:

Therapy providers by and large try to continue therapy at a level that was demonstrated during the assessment period. However, outside of that assessment period most providers are not watching the minutes as closely as during the assessment and as a result will sometimes not provide exactly enough minutes to warrant the same reimbursement. If that happens under this new proposal, those cases will result in a loss in revenue. Patients will basically be in an assessment at all times. This will be much more labor intensive to monitor, increase facility paperwork and probably result in losses for providers. This will also add significant workload for MDS coordinators. (At least they didn’t have much to do before.)

Likelihood: High

Change: Parity Rates

What it means:

After the changes CMS made in October of 2010, they expected to see a reduction in cost. (By “expected” I mean “was counting on”.) After those changes, reimbursement to providers actually increased by 2.1 BILLION dollars! CMS would like adjust the rates to recover all the money they feel they have paid out by mistake. However if you look at the proposed rates, an RUB for example will pay $86.51 per day LESS under “parity”.

Bottom Line:

This one is pretty easy to understand: You will be making less money from Medicare and Medicaid than you used to. This one doesn’t just apply to therapy.

Likelihood: Medium

Change: Medicare B caps

What it means:

You are probably already familiar with Med B caps. We’ve been dealing with those for a long time now. There is an exception process in place, the KX modifier which allows therapy to continue provided the therapist can attest to the need. The exception process allows therapists to continue treating patients that need therapy after the cap has been exceeded.

CMS would like to end the exception process. That would limit a Part B patient to a little over $1,800 per year for speech AND physical therapy combined.

Bottom Line:

This change would be very similar to yelling “Fire” in a crowded movie theater: there would be a lot of panic and when things settled back down there wouldn’t be a lot of people left. This change will be a fundamental shift in skilled nursing. Far fewer therapists would be in your building. Far fewer residents would get therapy. Much less revenue would flow into the building from Medicare A and Medicaid in case mix states. This one wouldn’t be pretty.

Likelihood: Medium (I would have said low a year ago but things have gotten much worse in the last 12 months. Most states do not have solvent Medicaid programs.)

You might be thinking: “I use contract therapy so I don’t have to worry about any of those.” Have you considered what might happened if your therapy provider failed? If your provider doesn’t understand Medicare and Medicaid reimbursement (not just therapy) and how these changes will affect the bottom line then guess who has the problem?

You really need to educate yourself about the proposed changes and what they might mean for you. Ask your therapy provide what plans they have for each of these four possibilities. If your provider is unaware of any of these changes, or doesn’t have good answers, then you have a problem. The good news is you have until October 1^st to get it all figured out, although some people haven’t figured out MPPR yet and that took away 8-11% of your Medicare B revenue starting January 1, 2011. 

Why Do Nursing Homes Focus Only on Cost?

I speak with a lot of nursing home administrators. One thing I have noticed is admins are focused mainly on costs and less on revenue. Some are so focused on cost that they ignore revenue altogether. Here is an example conversation that I have had many times while consulting with SNFs:

Me: "You will have to pay for some software to help you do the job properly."

SNF Rep: "Not interested. I don't want to increase my costs."

Me: "The costs are a small fraction of the reimbursement increase you will see."

SNF Rep: "But my costs will increase, right?"

You can see where that is going: nowhere. I have had that conversation so many times I can't tell you.

After much thought about it, here are three reasons why I believe this happens:

1.       Cost is simple and easy to understand

Costs are so basic that everyone understands them. When you write a check you end up with less cash than you have now. That's not fun so you try to avoid doing it. Some admins see all costs as something to avoid.

2.       Reimbursement is complicated

The flipside of the cost argument is that reimbursement is far more difficult to understand than costs. Medicare and Medicaid have thousands of rules that are constantly changing. Given all the responsibilities nursing home administrators have, there simply isn't time to learn all the gory details of reimbursement. Well that’s a problem when it comes to Medicare. You can't optimize something you don't understand.

3.       Acuity “is what it is”

Some admins believe that reimbursement "is what it is" because patient acuity "is what it is". They leave the billing to the MDS coordinator, whose job it is to understand the Medicare rules

Like all good myths, this has a nugget of truth in it:  acuity is what it is. But it’s not the acuity that’s the problem, it’s the way you go about recording information on the care that was provided matters.  I have seen many examples of customers increasing reimbursement by hundreds of thousands of dollars a year if they will simply look at the entire picture instead of just focusing on cost alone.

Contact me if you want to focus more on your revenue.

The 3 Stages of ADL Scoring Evolution

I talk to a lot of different skilled nursing facilities. I've seen every level of sophistication when it comes down to ADL scoring. With all the different approaches however, they still all boil down to three different categories. Which one are you in?

Stage One: Paper

Accuracy Score: D-

Reimbursement Score: C-

Audit Risk: C

This is the stone age of ADL scoring. ADL scores are usually written on a sheet of paper that shows all three shifts for a month. CNAs can see every score the patient has received for the month. It's easy to copy and keeps you from having to understand what the scores actually mean. It's easy to defend your score if it is the same as the one before it, or so the logic goes. Accuracy on paper systems is very poor. I have seen thousands of ADL grids over the years and most of them have the same score simply copied from shift to shift, day to day.

Reimbursement on paper system is average to poor. This sounds a little surprising but I think it's because CNAs will tend to select a score in the middle of the scale. They don't want to have to choose an extreme score because that might look strange to someone, somewhere, at some unknown time, assuming someone actually looks at this stuff or understands at all. I once had an authority in government tell me that 99% of homes are underpaid because they don't understand ADL coding and the government is fine with that. 

You might be surprised to see the audit risk is scored as average for paper. It's certainly not because there aren't a lot of reasons an auditor could deny your claim with a paper system. Believe me seeing scores like 8,3 would be pretty easy to deny. (Activity did not occur with two person assist) Look at it like this, auditors could deny your claim but haven't chosen to yet. Does that feel comfortable to you?

The number of stone agers is still reasonably high. It's surprising that a couple of large chains still use paper. It seems like an inexpensive way to do ADLs until you understand what it is doing to your business. Ignorance is bliss but it's expensive too.

Stage Two: 1st Generation Software

Accuracy Score: C

Reimbursement Score: C

Audit Risk: C

These stone agers have discovered fire and they're running around it giving each other high-fives. They got a touch-screen system that records ADLs and probably a lot of other things as well. They have lots of reports that probably say lots of interesting things. They print out ADL scores and put them in the patient record. As far as management is concerned, they have arrived at the future.

However, once you take a closer look, things aren't all that much better. CNAs still need to enter a score for each patient. "Was that limited assist or extensive?" They start using memory aids like the four Ts. "Well I touched this patient so that's limited." That makes it much easier for CNAs, unfortunately it's completely wrong. Independent anyone? Not possible with the 4Ts. The RAI definitions for ADL scoring don't look anything like the 4Ts. There's a reason for that.

As far as reimbusement goes, 1st generation software is average. You might have noticed that the same score the paper system got. That's because when you boil it down you are having the CNAs do exactly the same thing they were doing before. Namely, understand the ADL scoring definitions and correctly apply them. The only difference is that they enter the number they don't understand into a computer rather than on a piece of paper. But hey, you've got some nice reports right? You're looking at all those reports right?

So the audit risk is at least lower, right? Well most software systems will stop you from putting nonsense scores in so that's better. The risk here comes from the indefensible definitions being used.4Ts? Palms up = Extensive? Staff does more than resident = Extensive? These are all simply wrong and subject to denial at any time. You are probably thinking "I've been using those definitions for years and have never gotten questioned about it." The problem is that you are operating outside of the rules and could be denied at any time. At least you can take comfort in the fact that Medicaid is flush with money and not looking to make any cuts. Oh wait...

There are a lot of people who moved into this stage and most of them are pretty happy. They confused the goal, accurate scoring, with the means, software. Using a computer to score your ADLs like you did on paper is completely missing the point of using a computer. Using a computer was never the goal, accuracy was. Oops.

Stage Three: Enlightenment

Accuracy Score: A

Reimbursement Score: A

Audit Risk: A

If you read the RAI manual you will see that CMS recommends that you "ask probing questions". (Chapter 3, Section G, page 3) Does that sounds like what's happening in the first two stages? People who have reached this stage realize that the ideal situation is for an expert to interview your staff at the end of every shift at minimum, ask probing questions about what the resident actually did (not what he or she might be capable of doing) (Chapter 3, Section G, page 2). Then your expert would collect all those scores, aggregate them correctly and produce and ADL score that is accurate. This would need to happen every shift, every day, forever.

Now that's a job fit for a computer! That's exactly what MDSMax does. We're not replacing your MDS coordinator, we're just helping collect accurate data and help to suggest a good day to do an assessment. You're probaby thinking "Good idea. Why just interview for ADL scores?" We agree. We interview for behaviors and bowel and bladder too. CNAs answer simple yes or no questions on a touch screen. We tailor each interview based on the responses we get to quickly get to an accurate ADL score. Accurate every time.

Here's the surprising part: accuracy = higher reimbursemet in skilled nursing. Undercoding is the norm in skilled nursing. If you don't understand the definitions then you tend to gravitate towards the middle scores out of fear. That ignorance is costing your facility a LOT of reimbursement. 

MDSMax uses the exact, word for word definitions for ADL scoring that CMS uses. Where possible, we use questions that CMS has suggested are appropriate "probing" questions. We've never been out of compliance on hundreds of audits regarding MDSMax data. When the audits start to get tougher MDSMax will safe harbor.

MDSMax is different. We're interviewing your staff regarding the care they provided. We believeMDSMax is exactly what CMS has described as the ideal way to get accurate scores. We would love the opportunity to show you how much better life can be with some peace of mind. Get a demonstration today.

5 Reasons CNAs Under-Code ADLs

One of the main reasons we developed MDSMax is that CNAs consistently under-code when it comes to ADLs. They don’t do it on purpose. They're set up to fail. Here's why:

5 - Poor understanding of the importance of ADL scoring

CNAs have a lot of things on their plates. Taking care of residents can be a demanding and physical job. Deciding whether you did "limited" or "extensive" assistance doesn't seem that important by comparison, especially at the end of the shift. The problem is that the financial success of your facility is riding on those scores. You need scores to be correct.

4 - No feedback - "Was I right?" - Who knows?

Once the CNA puts that score in the box it will probably be at the minimum three days before someone with some knowledge even looks at it. By this time the odds of even remembering it are pretty slim. Once the score is used in the assessment, it can be six more months before the effects of that coding are finally realized. With feedback this slow, correcting problems is tough.

3 - Safety in numbers

A lot of places still use paper to track ADLs. If that's you then you're already starting out in a hole, but it gets worse. When the CNAs can see the score the last shift put down, what score do you think they're going to use? They don't want to be wrong, but if they are, they'd much rather not be alone.

2 - Poor training

I've met people that believe the difference between "limited assist" and "extensive assist" is which way your palms are facing. Sounds silly right?

Okay, ask yourself this: If a CNA lifts a patient’s leg back into bed during the night, how do you code that? You said extensive, right?

How about this: You help a resident stand from a wheelchair next to the toilet. That’s a transfer, right? Actually no, it’s toileting.

Surely you train that straightening a resident’s clothes after toileting is limited assist, right?

Ignorance is rampant when it comes to ADL scoring. If the person training your CNAs how to code doesn't understand the definitions, you've got no chance getting meaningful scores.

1 - "Paper Software"

You know that $30,000 software system you purchased so you could have an "EMR"? Have you noticed that ADL scoring isn't much different now than when you used paper? CNAs still need to understand the definitions. They're still picking numbers to put in a box. The box is just on a computer screen and not paper. You may have pretty reports but it's the same wrong data you had with paper. Sorry.

How can you make sure you aren't under-coding? Well the ideal situation would be for you to hire an expert that really understands ADL coding. That person would then ask your staff probing questions to determine what really occurred during the shift. Then your expert would document those scores and correctly calculate not only the daily score, but recommend an assessment day for you. You'll probably want one per shift and not allow vacation or sick days. Or you could just get MDSMax - your call.