MEDICARE HMO'S

[ibtootie]

What is the appropriate eval for a patient with a Medicare HMO? PPS or OBRA?

[andy3k]

"What is the appropriate eval for a patient with a Medicare HMO? PPS or OBRA?"

If your state requires you to submit MDS for all residents then you must, of course, follow the standard OBRA schedule, even for Medicare HMO residents.

If the Medicare HMO requires that you submit a RUG then they will probably tell you what kind of MDS they want for you to complete (e.g., follow the PPS schedule) so ask the HMO.

CMS has said that they do not want Medicare HMO MDS records. Their preference is that you use a separate software product to enter the MDS and get a RUG. If you must enter the Medicare HMO MDS into the same software as all the rest of your MDS, you can set the A0410=1 so that it does not get submitted to either CMS or the state.

Bear in mind that if you follow the standard PPS schedule per Medicare HMO request, and then the resident becomes Part A, you MUST start the PPS schedule over e.g. 5-day, 14-day, etc. The Medicare HMO schedule you followed is irrelevant when you switch to Part A because CMS doesn't want the HMO PPS records and you shouldn't be sending them. I know that CMS has said something to the contrary in past conference calls but my coworker and I have decided that CMS had not thoroughly considered their answer before giving it.

[Talino]

The RAI, p5-1 does specifically states...

Skilled nursing facilities (SNFs) and hospital swing beds are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF PPS.

HMO Medicares are not reimbursable under the SNF PPS, hence the MDS assm'ts are not transmitted, as andy3k stated. However, there is no need for a separate software. Complete the HMO MDS as if it were a "true PPS MDS" (using the same assm't types- 5, 14, 30, etc. as required by HMO) in order to get the correct rug score. Once the MDS is complete, save it in a different file, or print it then delete it from your MDS history. Keep the MDS for HMO review.

I posted comments to a similar scenario here.

[andy3k]

I had thought of Print & Delete but my coworker told me that sometimes you to resend an MDS at the HMO's request, make corrections due to entry or collection error, etc. and that takes more time when they have been deleted out.

[susanthomas1954]

I actually put my HMO PPS MDS's in a separate transmission file that I don't transmit. I have "a" for Medicare, 'B" for OBRA and "n" for anything I don't transmit. Since i transmit 2/wk, I can easily retrieve something from an "n" file and transmit, if it turns out to be a Med A pt.

ST