Hi! I work in a skilled care facility. While working another mandatory overtime 11-7 , I had a little extra time to look through some resident charts. There are about a half a dozen residents on my unit who do not appear to be skilled care material. For example there is a female resident who is continent, self care Adls, ambulates in her room and is A&Ox3. Goes on LOA's with her family practically every day. I look at her assesment data and see on her MDS from 3 months ago that she is given all 3's and 4's. She is not a medicare pt. I examined a few other charts and found similar examples. The nurses' and CNAs' documentation is vastly different than the MDS codes. I went to MDS nurse with my findings and she couldn't give me much of an explanation. I talked to the Diet Tech who is also a member of the "team" and she immediately ran to administration. Administrator and my DON called me down for an interview. They offered no useful info but I must say they were EXTREMELY nice. They talked of how difficult it is to discharge residents from the facility. I said to them "Isn't it true that the higher the numbers on the MDS the greater the reimbursement?" Didnt get a straight answer. This was some weeks ago and nothing has been done. Shouldn't there be significant changes innitiated and new MDSs done? I am not that knowledgable about PPS but it looks like fraud to me. What should I do/
Feb 23, '01
Right you are. I used to work as an RNAC, and the higher the ADL score, the higher the CMI score [case mix index].... the higher the CMI score, the more $$$$ per day the SNF gets for caring for the patients.
I can offer you two possible explanations. Both mean that there is a big problem:
The first, has to do with stupidity- that is your MDS coordinator is entering stuff about the patient that they THINK is correct. This happens when the RNAC fails to talk to the CNA's & the LPN's to get the real facts about the care needs of the resident. The rememdy is simple... they should initiate a 'significant correction of prior full assessment' on each of the residents and get the ongoing imput of the LPN's and the CNA's to prevent such gross representations of care needs of the residents.
The second scenario: They are intentionally lying on the MDS about the care needs of the residents to artificially inflate the CMI for bigger reimbursement- which is illegal. In which case, I would contact your state's department of health as well as your state's UMR [Utilization Management Review- the 'police' of the medicare/medicaid programs], and/or your state's auditor general and send your RNAC and NHA [NHA has to sign the CMI report 'attesting' to the accuracy of the CMI]-to MDS hell for a long time. Also, if they recover any money because of you, they usually 'cut you in' for a percentage of the funds. Merry Christmas!
Either way, something needs to be done about it.
Feb 23, '01
Who is paying for this patient's care in your facility, an insurance or the family? If it is an insurance company,why is she still there...needs 24 hr supervision and family works, receiving PT for strengthening or IV therapy? You have some valid concerns...as a home visiting RN,I NEVER heard of difficultly discharging clients to home if supportive family. Greatly concerned that staff documentation and MDS plan don't match, brought to administration and no changes made.
I would be very careful in my documentation and watch your back now that administration kows your aware. If you strongly feels it's fradulent and just not sloppiness/MDS nurse not fully checking charts you have 3 recourses: 1. copy the chart info on several days and MDS plan( if possible) on several different clients to prove it's a pattern or write down info in copy book at home: patients name, ID number SNF days, your care recolections etc. and report the facility as whislteblower ---if this action taken be prepared to be dismissed and need to find other position, possibly have reputation smeared. 2. Keep working and try to met with MDS RN---be prepared for unemployment if too much resistance. 3.Leave now, find another position then report facility.
In my area, a DON reported the SNF facility as she was constantly being nugged by corporate to upcode clients-reported facility in 1999, was fired and cas came to light only last month. She was hired in a totally different area only after 6 months unemployment. Only you can judge what is best. Good luck and let us know what you decide.
Feb 23, '01
Tim and NRSKaren are right. Sounds awfully suspicious. (I am ex-MDS nurse). Do they have several decubiti? Are they on continuous O 2? But regardless, no skilled care patient should be going on LOA almost daily.
Feb 24, '01
Hi. I agree that Tim and NRSKaren are correct. It is outright fraud and no matter who the payor source is, all taxpayers are ultimately going to be affected. Not only that, it does a disservice to that patient and family to not be upfront with them regarding their needs. The patients that Nebby Nurse describes are custodial. They have no business being in a SNF.
This is the dilemma that I see when it comes to families needing help with older or disabled relatives. Many of the people that have custodial needs do not have the personal funding to pay for assisted living, private homemaking and CNA services or even an ICF for those who want to avoid spindown.
Tim, Karen, et al. what can be done to steer these patients in the right direction before they get exploited like this? Do you feel that the monies that have recently been legislated will help reduce this type of fraud?
Feb 24, '01
First you have to look at the Assessment Reference Date first which is Section A3a of the MDS. Then you count within 7 days back from this ARD and check if the ADL functioning of the resident was coded wrong in Section G for this period.
If the resident's payment status is Medicare at the time this MDS was done
Yes, the ADL score particularly bed mobility, transfer, eating and toileting will affect reimbursement directly.
Meaning if ADL index is 13 and above,facility gets reimbursed at a higher rate.
There is always the option to make a significant correction of prior assessment if the coding was inaccurate.
Do not be too harsh on your RNAC.
Find out the reason why the ADL scoring does not reflect a true picture of your resident. Maybe your RNAC is overwhelmed and is having difficulty meeting the demands of
her job to complete hundreds of MDS for such a limited time.
If you don't have basis to accuse her of
purposely coding ADLS higher to get maximum reimbursement, help her out that she will be able to correct the mistake and place the proper coding.
If you think most of the MDS in your facility are purposely being coded wrong just to get a higher reimbursement and you have enough proof to prove this in court,
go right ahead and report this to the State.
Mar 2, '01
Thanks to all for your input and support. I continue to review charts and have found ten charts where the MDS codes are not supported by documentation. It appears it is a combination of deliberate intent and a "I dont't give a **** " attitude on the part of the RNAC. Administration is only concerned whether or not I intend to notify the state. They are not aware of how many discrepencies I have uncovered. Being a cautious person, I am still thinking over how to proceed. No attempts have been made to rectify the stuation and it is absolutely infuriating. I will let you all know what happens. Thanks again!
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