PDPM takes into account the systems at your facility. Unfortunately, those systems are not always functioning at a high level, which results in flawed documentation in long term care software that could create major problems for a facility. Here are the tell-tale signs that an administrator should look for in order to avert disaster:
1. Insurance is Being Charged for Rates, But the Facility is Not Receiving PDPM Reimbursement
The first sign that the system is broken occurs during the first ten days following the admissions process. The MDS nurse might claim a particular rate, but the insurance company does not reimburse the facility for that amount. This is an indication that the documentation submitted to insurance companies does not reflect what is being claimed. Ideally, these errors in documentation in nursing home software are caught by the MDS nurse, though that is often not the case.
Fortunately, these mistakes can be easily fixed. It is mostly a matter of ensuring that the admissions coordinator receives not only an active list of medication but also the resident’s historical medications given during hospitalization; the MDS nurse needs to enter the historical data surrounding the resident in the facility’s long term care software or long term care EHR. For instance, the resident may have received IV fluids at some point during his or her hospitalization. That is enough to modify their daily rate. It is, then, wise to work in accordance with checklists.
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2. The Resident Meets Criteria for Which There Is No Electronic Nursing Documentation
An MDS nurse may make a mistake on a form or even falsify records in the long term care software system during electronic nursing documentation. This is likely because he or she knows something about the resident but does not have the documentation to support it.
This issue can be fixed with a bit more communication. The MDS nurse should be bold enough to tell the DON what he or she needs. But when that does not occur, it is the administrator’s job to relay the issue to the DON, who will request that a note be added.
3. A Resident Suddenly Stops Requiring Assistance
A resident that required two-person or one-person assistance may no longer be charted as such in a long term care EHR because CNAs are not doing their jobs well. This could be the result of one mistake that is then embraced by others, or parrot charting, which will be discussed below. It is the MDS nurse’s job to find the point in time in which a resident is charted differently in the long term care software system and confront the CNAs responsible.
4. The Day Shift and Night Shift Contradict Each Other
A nursing home may have two or three shifts in a day, and a resident might be seen by three or four nurses in a week’s time. It is important that those various staff members are reporting the same thing. If not, something must be wrong. If the day shift, for instance, charts a resident as a two-person assist, and the night shift says that the same resident is independent, there is clearly a problem. Yes, there are differences between the care provided during the day and at night, when residents are usually asleep. But some gaps are too big to be explained away and may present a confusing picture, raising questions about compliance and reimbursement.
5. Lack of Communication Between the MDS Nurse, Therapy, and the Business Office
A lack of coordination between the various parts of the systems in place at your facility will often only show up after billing has been processed. That means that, after billing Medicare, you will have to wait 30 to 60 days just to realize your mistake and then another 30 to 60 days after correcting the error and filing for the second time.
It is, thus, important to ensure that MDS nurses, therapists, and those involved on the business side are on the same page. In reimbursement meetings, physicians and other clinicians will gather and present the care concerns for the resident. Meanwhile, the administrator will be concerned with the financial side. The following examples help demonstrate the competing concerns of the various members of your team.
Example: A resident wants to return home in six days and only has four days of Medicare left. The administrator will need to take the bottom line of the facility into account and perhaps call to move the resident to home care or private pay earlier than he or she desires. The DON, meanwhile, is concerned with the proper time to stop IV treatment. The social worker wants to ensure that the resident will be able to make it safely to the car after being discharged. These various concerns must be resolved in a way that ensures the best interests of both the resident and the facility.
Example: A resident may only have 10 days of Medicare coverage remaining. The therapist, meanwhile, determines that the resident needs another 30 days of treatment. The business office manager will have to find the necessary resources and present other payer options to family members, like Medicare Part B, Medicaid, other insurance, or private pay. Home health should be discussed as well. If no resolution is found, the various team members may have to decide that the facility can no longer provide the necessary treatment for the resident after those 10 days have passed.
If the relevant parties at your facility do not see such matters eye to eye, that is a good sign that something in the system is broken, which will negatively impact care, reimbursement, or both. Because calculating a PDPM score in your long term care software system is a complicated process with a lot of moving parts and various systems, the key to perfecting reimbursement is the vigilance of your MDS nurse, the driver of the entire process. This means that he or she must ensure that CNAs know what to document, check on residents for potential conditions, and look for inconsistencies. Of course, the MDS nurse must also be managed and encouraged to actively pursue reimbursement. That is why the other leaders at your facility also play an important part in the process.
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