Nursing Homes will be facing a RUG Utilization review in the near future. This review will cover the years from 2008 through 2010 for MDS 2.0 items.
What it is and how it works
Reviwers select a group of residents from predetermined RUG categories. We have all read how Medicare/Medicaid is going after the therapy RUGs claiming this is the most abused category. However, surveyors are also targeting the ADL RUGs. Any error found for one resident RUG causes the surveyors to “extrapolate” that everyone in that RUG group is incorrect. That will lower the RUG across the group. This adds up to a lot of money of claimed overpayments.
Imagine 35 residents being lowered from PD1 to PA1. That adds up to $23.90 per day per person over the Certification period (90 days). That is 75,285 dollars in over payment they can claim and that does not include your “error rate” multiplier. This number can rapidly multiply.
Tips for the Review
These reviews are unannounced, but there are ways that you can prepare. Make sure your stored documents are in order. During the review you have the right to be shown every error they find and produce any additional documents that support your original MDS coding. Insist on that. Our experience has been that the surveyors have rarely shown errors to the facility and asked for additional documents. The person who interacts with the surveyors must know this and insist on this being done, so it is wise to have a strong person in that position.
The Exit Conference
Read what you are signing. If you were not shown every error they claim and given an opportunity to produce additional documentation, don’t sign any document that claims you were. You will be given a “List of Reviewed Assessments”. This lists each person in a RUG category they reviewed, any errors found and the RUG changes. ASK what every item means and why. This will be your only chance to do so.
Do not be fooled by what you see. You may see several errors and a mass of dashes. Those dashes are errors too. What initially looks like an easy rebuttal quickly turns into 150+ errors.
Call your legal counsel the moment the reviewers leave your building. A small error rate equals a large amount of money owed. A small 5% error rate can be over $100,000.00 in recoupment the state will claim you owe.
The state gives you 15 days to respond in writing to every error, and your legal team will need every second of those 15 days to do so. By getting the List of Reviewed Assessments to your attorney quickly, they get a head start on this process.
Next week – Drilling down to ADL MDS errors, the how and why money is walking out your door