Pushing The Limit For $

Specialties MDS

Published

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"...:bluecry1: 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... :banghead:

Specializes in Hosp, SNF.

That is my take on the subjecct, and thank god , :yeah:

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thanks to the original poster, i had this exact same question. just took a job at a new facility and they typically skill someone even after therapy has stopped until the day the omra is due and then cut them if there is no "decline". this makes me nervous because in my previous job once they were cut from therapy and nothing "nursing" was going on, we cut them from part a.

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Specializes in Geriatrics.

I was being pushed also to do "off cycle" quarterlies to capture a better RUG for case mix. I was very hesitant to do this, but I called my state MDS coordinator and explained it to her and asked her opinion. She said there is nothing in the RAI manual that says you can not do that, and in fact, most facilities are doing this, but too many does raise a flag. I believe one day this loop hole will be closed, but for right now, it is open to jump through.

As for the medicare questions, refer to Chapter 8 in the Medicare Benefit Policy Manual. You should not be skilling people that are not in a skillable RUG category. When therapy ends, we monitor that resident for 7 days, then if there is anything nursing wise to skill for, of course, an OMRA is completed. If not, they come off of medicare.

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Specializes in Hosp, SNF.

Yes, I have also joined that "crowd" the facility is so going for the big $" that I am doing extra Quartely's on every applicable state resident to up the score for Case Mix, ... and to top it off isn't it a miracle that these peopla are all of a sudden getting Restorative Therapy and it just happens to be during a lookback period, it's a MIRACLE.... I can not imagine that the Dept of Health?CMA?State who ever, is going to allow this... I really feel this is not right... and my stance, if it ever comes up , will be I was told to scedule and assessments, I did, I completed it correctly based on the manual, I am glad I am not the OT or PT providing the therapy, because I would really have a hard time justifying this practice, even if "everyone else is doing it", I am not putting anything false or incorrect in the MDS to bump up the score. I am actually at 2 different compainies, one is so very reasonable and doing the right thing, the other is just all for the $, and this is horrible. AT this "other organization" I am no longer doing MDS to improve the lives of my patients, I am now completing MDS for a "for profit organization" to gleam every last penny, even if it takes me hours to get that PC1 to be a PC2 and have the RUG score jump up by .02... and it makes me sick.....and heartbroken, I did not become an RN to do this....

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Hi--a few questions--and a comment...

  1. If you do "extra" quarterlies, does that also mean "extra" care planning sessions in "sync" with the quarterlies? Or does the care plan session remain quarterly?
  2. Does your software allow you to enter "extra" quarterlies (so you might do 6 instead of 3?) Or just do early quarterlies?
  3. If you do "extra" (or early) quarterlies, does this also mean "extra" (or early) annual/comprehensives? Therefore, also "extra" (or early) RAPs/CP sessions?
  4. If you do "extra" or early MDS, do your compamy policies allow you to do so? Or do the policies state that your will comply with the OBRA and/or PPS schedules?

IF you do "extra" or early MDS, this means alot more work for the whole team. Has management or "corporate" "costed out" this extra expense? Time = $$$. More paper = $$$. If this new RUG raises the rate by $5/day, is $150 worth it? Resources expended are far > $150!!!

IF the MDS and CP do not "sync", we have defeated the purpose of each--$$$ wins!:bowingpur

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Specializes in Hosp, SNF.

I am all in agreement with the extra $ spent for the staff to do the work, but since we are salaried, we are expected just to get the job done, so , the facility believes they will win more $ in the long run pushing the slave/salaried mds workers get the job done and hunt and peck out those RUG's, can you tell, yes I am annoyed at this practice !!! And no, they do not cange the meeting schedule nor the annaul, they are just extra quarterly's, and no , there is no policy and procedure for this.....

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Specializes in Geriatrics.

This is new to our facility, not really to sure of what to expect ( living in New York probably will never be sure ). We ran the gammot of reimbursment " updates" as referred to in many of your comments. It seems like walking a very unsteady tight rope between meeting DOH regulations for survey and ensuring accuracy in RUGS for reimbursement - if RUGS increase too quickly or too high that triggers sig. changes and red flags for the DOH as to why the rapid decline.:eek: I find I am questioning the sensibilities of climbing the perverbial " ladder" more often now - wishing I was back to being a staff nurse or even a CNA again - where my heart lies - actual hands on care good old fashioned nursing!:nurse:

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Specializes in Hosp, SNF.

You are so right and this whole thing is heart breaking. Now into the second attempt at the case mix upload for NYS reimbursement, I find that my MDS role seems to no longer be to get the best patient outcome but to get the best fiscial outcome. I am no longer a nurse during these "capture periods", but a number cruncher, and I am heartbroken and frustrated as I have loved doing MDs in the past and explaining how the whole process works from getting someone in the door to MDS creation to care planning for the best patient care possible, now my whole role is focused on eeking out that last little bit of 0.02 to a RUG score. The interesting thing is that in one facility I am part time and they are the ones really pushing , pushing, and in my full time job, this is not happening. Amazing how one corportion is really smart and one is really pushing the limits:banghead:

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Kristen LPN if you can please send me a post so i can chat with you about RUG payment source Texas started this and i still kind of confused thanks sissie43

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Specializes in Care Coordination, MDS, med-surg, Peds.

you can only do quarterlies no closer together than 92 days, so you aren't going to be able to do THAT many extra quarterlies in a year. If there is an audit, I would imagine the Admin would get in big trouble, but then you may be in trouble as well for medicare/medicaid fraud if this is the case. I would RUN, no walk away from that job!!!!!! We skill ours for only a short time if no rehab is needed, for med changes, behavior changes, etc., 7-14 days, to allow for the 14 days available for sig changes, or look backs. I would be very careful and cover your butt.

according to may RAI manual"The RN assessment coordinator is not certifiying the accuracy of the portions of the assesssment that were completed by other health professsionals.''

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you can only do quarterlies no closer together than 92 days, so you aren't going to be able to do THAT many extra quarterlies in a year. If there is an audit, I would imagine the Admin would get in big trouble, but then you may be in trouble as well for medicare/medicaid fraud if this is the case. I would RUN, no walk away from that job!!!!!! We skill ours for only a short time if no rehab is needed, for med changes, behavior changes, etc., 7-14 days, to allow for the 14 days available for sig changes, or look backs. I would be very careful and cover your butt.

according to may RAI manual"The RN assessment coordinator is not certifiying the accuracy of the portions of the assesssment that were completed by other health professsionals.''

My consultant says the quarterlies can not be any further apart than 92 days but can be closer together. So if you have a res due for a Q in a month and notice right now they had a PICC line put in for IV ATB for 10 days, then you should do a quick quarterly to capture all that work. Otherwise you have to eat the cost.

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Hi! The MDS 3.0 RAI Manual makes it very clear that a quarterly is a quarterly is a quarterly. So one early quarterly COULD be okay. But not 8 quarterlies in a year. The pattern is comp, qtrly, qtrly, qtrly, comp.

Am kind of surprised that your state Medicaid agency hasn't directed facilities to prepare/submit an MDS when the special service has ended!

But these "extra quarterlies" may be problematic when/ if we transmit assessments to a CMS database, with transfer to the State (reverse of now).

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