Pushing The Limit For $

VeryberryRN · Oct 6, 2008

So frustrated !! One of the places I work has a administrator who is really pushing the lmits of Medicare.. this goes beyone Ruging for Dollars, way into me thinking... "if this chart gets pulled for review Medicare will take back every last cent"... Nurses notes are lacking or the same old , v/s stable no signs of infection, etc... this administrator is having me cover individuals who RUG out at PA1... ( he/she was in a psych hosp with a 3 day stay ), PD2 (he/she went out for mental status changes, pulled out the IV, had po abt and RUG out at PD20, therapy ended 2 weeks ago and we are mointoring them to be sure they don't decline... on and on and on...I feel as if this is fraud, not even pushing the limits, myself and other nurses, therapists are feeling the same way, we rool and eyes and whisper under our breath, oh my god, how are we going to justify this ? :argue::argue:Everytime we review this with the administrator, he indicates this is all coverable and appropriate under Medicare Part A for skilled observation, and I am reeling, what are we skilling for ?!?!? I'm so glad that all I do is complete the MDs and not be held liable for the decision to keep the person on, I'm okay , right ? I am not making the medicare decision, of course this is documented no where, should I worry if Medicare comes looking ? I am doing the MDS correctly, if nothing happend in the hospital stay or look back period, than nothing happened... but , this is all making me very very ill...thoughts please , no , I cannot quit, and no, I can't go above the adminstrator, been there done that all I had was negative outcomes for me...

You are really in a no win situation. You are absouutely correct to be concerned. Your administrator is making decisions for your entire team that can get the entire team into trouble. My concern would be if he is as unscrupulus as you say that he is, when it comes time for a Medicare audit, he will blame anyone but himself for a bad audit. The key to the game is documentation! Protect yourself. :nurse: Make sure you can back up what you put in that MDS.:typing Good Luck!

disney158 · Oct 7, 2008

"he is as unscrupulus " His vision of this theory is that it is perfectly okay, even spoken about in all of the Medicare pushing the RUG dollars we have all gone to... indicating the system was set up by Medicare so why not use those rules to our advantage ... , back to my basic quetion, what touble can the team and I get into ? Now I feel ill.... :sniff: :eek:

VeryberryRN · Oct 15, 2008

Sorry if I didn't answer your question. I don't think you can get into any trouble technically. Your administrator is the one that will have to take the heat with Medicare. I am having a similar problem, but it concerns Medicaid. Recently we have switched from using the PRI for Medicaid reimbursement for the MDS. My Administrator,DON, and I went to a workshop a couple of weeks ago that told us that we can move the Quarterly and Annual MDS dates during the "picture dates" to improve the scores. Even do quartery MDS's as close as weeks apart. We have not heard this officially from the DOH as yet, but the picture date period has started, and My administrator of course wants me to begin to move the MDS's when residents are ill, or picked up for PT to improve their scores. I am very leary that we are creating a logistical nightmare that we will have a very hard time getting out of. Does anyone else from other states that have been being reimbursed by the MDS for awhile have this problem? Heeeeeeeeeeeeeeeeeeelp? Confused in NY! :banghead:

disney158 · Oct 15, 2008

I too am in NY and we too have all been to the same workshop, as if it isn't bad enough to do the calendar right, now we will be playing the "move the ard" game for NYS reimbursement also, I have some clincians who still can't get the right dates no matter how often I go over it, I am told I am talking "MDS", did you know that "MDS" is no a recognized language of it's own, ... and these are smart people..

gizzy81 · Oct 20, 2008

I would be concerned too. I was always taught that if you were going to skill someone the RUG score must be above a CA1. This is a medicare skilling RUG score. Do you have a nurse consultant or anyone you can talk to, to voice your concerns to.

disney158 · Oct 21, 2008

Nope, no-one... corporation is now purchased by a new owner, so we will see what happens, as we know, new owners sometimes "clean house" so i won't have to worry, maybe the administrator won't be there too long.. I can always hope....

cmsnurse49 · Oct 21, 2008

I work in Texas we just recently went the RUG 34 to replace our TILE payment system for Medicaid. But before I start on that let me comment to the ADMIN problem... I have been working in LTC for 31yrs, 15 of which I have been doing MDS's, TILEs ie. It has been my experience that if you make someone responsible for their actions they will usually come around. Have the ADMIN sign the MDS. Say that it is for accuracy. Any how.... all disciplines that have input in the assessment are to sign. Sounds like he has quite a bit of INPUT. Back to the above - I have taken a position with a company as a Case Mix Resource Nurse. We look at MDS and find the "best" RUG rate. At this moment there is no rule in how often, or close together you can complete an MDS - but I believe that will change.... Because the almighty state :bowingpurwill not abide with so much money going - not to LTC facilities...

edhcinc · Oct 22, 2008

This is a very interesting thread. Although there are no statements in the RAI Manual re: how close together OBRA assessments can be scheduled, it is clear that the schedule cycle SHOULD last approximately one year. The care plan is developed or reviewed following each assessment. Compressing the OBRA schedule for reimbursement purposes is not explicitly disallowed.

You say that a workshop presenter informed you that you could "flex" the ARD within the "picture" dates--I presume that follows SOME sort of guidelines, like the PPS schedule, where the ARD could be (+) 4 or 5 or (-) 8 to 10 days of the "target" date. (as long as completed within 92 days of last quarterly or 366 days of last comprehensive). This would be reasonable, as it would also allow staff to schedule assessment dates to allow for staff vacations. Clarifying ARD's with your state RAI coordinator or Medicaid agency, as previously mentioned, would "ease" your mind. Facility policies/procedures should specify the parameters for this flexible scheduling.

At one point we were cautioned NOT to submit quarterlies "early" to change the QI/QM. Am sure that the same "caution" would apply here.

Good luck!:cheers:

KristenLPN · Dec 18, 2008

I am in Illinois, who is going under what is called Medicaid Audits. If your facility gets paid thru medicaid, be leary over too many "early assessments" as this will send a red flag to them and guaranteed they will make a visit to your home. My facility went thru a "mock" audit, and that was bad enough. As for the administration ordeal, it is not going to matter if you make him sign the assessment or not, your signature is on it as well. As a matter of fact, I believe that all department heads sign the assessment stating that all information is true and correct. You are signing it as being the person completing the information. It is your responsibility in the end, no matter who comes in and "audits" you. Unfortunately, since you went to the chain of command and it did not work for you, you may have to make other arrangements of whom to talk to. In the end, it is your license on the line. :no:

disney158 · Dec 18, 2008

I really feel comfortable that when I sign on R2B I sign that the MDs is complete, not that it is correect, I will not sign for the sections that I feel are inerror, as I said, I am siging R2B, and the way I read it , that is only indicating the MDs is complete, this particular orgainization has been purchsed by a new owner and the $ stretching is not going away...here in NYS, the reimbursement has also changed for MEdicaid from a PRI to the MDs, and now at this particular place, we have lived thru inservices oto the CNA's on how to "document", of course the push is to document the maximum assistnace the cna gave at all times, once again, not illegal, just shy of it in my words, but all of the administrative people, feel this is totally appropriate and within all of CMS guidelines, we were just never getting paid the "right" way for all of our hard work before, so if a CNA provided hands on 1 time in an ADL activity, they are being told to put down assist of 1 for any minute weight bearing act, and even for those folks who eat, in the main dinning room, there is a nurse in there for all meals, just in case they are needed, and the folks are served resturant style, everyone is being ut down at least for supervision in eating, even if they are independent walkie talkies and can go into a returant and order a meal, becuase they are being "supervised" ...once again, I am arguing they are supervised because that is how we wet up the dining experinece, not becuase it is needed, HELP ME !!! So frustrated I can not spell right

fulzgold · Dec 18, 2008

I am in Illinois, who is going under what is called Medicaid Audits. If your facility gets paid thru medicaid, be leary over too many "early assessments" as this will send a red flag to them and guaranteed they will make a visit to your home. My facility went thru a "mock" audit, and that was bad enough. As for the administration ordeal, it is not going to matter if you make him sign the assessment or not, your signature is on it as well. As a matter of fact, I believe that all department heads sign the assessment stating that all information is true and correct. You are signing it as being the person completing the information. It is your responsibility in the end, no matter who comes in and "audits" you. Unfortunately, since you went to the chain of command and it did not work for you, you may have to make other arrangements of whom to talk to. In the end, it is your license on the line.

I was under the impression that the MDS Coordinator signs only that the MDS is complete. The person who fills out their area of discipline is who is signing responsibility for the accuracy. Right?