Feature
Minimum Data Set (MDS) 3.0 Accuracy:
Get This Building Block Wrong and There is No Reaching the Stars
Susan Chenail RN, CCM, RAC-CT, senior quality improvement analyst,
LeadingAge New York
T
he Minimum Data Set (MDS) 3.0 has never been more important to the financial
well-being of nursing homes. It has a major effect on Medicare and Medicaid payments,
various Quality Measures (QMs) and the Five-Star Rating System created by the Centers for
Medicare and Medicaid Services (CMS).
MDS assessments play a major role in establishing payment levels for Medicare Part A
covered post-acute care services as well as long term care covered by Medicaid through
Fee-For-Service (FFS) and managed care. The Resource Utilization Groups (RUG) score, a
measure of resident acuity used in both payment systems, is derived from the Activities of
Daily Living and Physical Functioning sections of the MDS.
If a facility inaccurately completes its MDSs and this has the effect of creating an
overpayment, the facility is subject to audit by federal and state authorities, and may be
required to repay not only the amounts overpaid, but also interest and penalties if the
facility knowingly submitted inaccurate claims. A facility that has been audited and had
overpayments identified is often more likely to be audited in the future.
Another danger related to inaccurate MDS assessments – perhaps a more insidious one – is
under-coding a resident’s clinical and functional status. Under-coding means that the MDS
does not reflect all the services needed or provided; essentially the facility is giving services
away while incurring the costs of providing these same services. This can obviously lead to
significant financial disruption and the need to take cost reduction efforts or other measures
to try to make up for the lost revenues.
There are a multitude of MDS 3.0 based QMs in the public realm. These QMs
are used to provide the public and others with indicators of quality of care, and
to establish pay for performance programs such as the New York State nursing
had overpayments identified is often
home quality pool. Thirteen MDS 3.0 based QMs are reported in the QM
domain of the Five-Star Rating System reported on the Nursing Home Compare
more likely to be audited in the future.
website. Examples of QMs that can be negatively affected by inaccurate
MDS assessments are prevalence of residents with pressure ulcers, residents who report
moderate to severe pain and residents experiencing one or more falls with major injury. An
inaccurate MDS can also negatively affect the care plan developed for the resident and, as a
consequence, the actual care the resident receives.
A facility that has been audited and
CMS’s Five-Star Quality Rating System has grown in importance since its inception. It is
used by consumers, referral sources, regulators, lenders and investors to gauge nursing
home quality. Nursing homes will be increasingly foreclosed from participating in Medicare
and Medicaid managed care plans, provider referral networks, various innovative Medicare
payment arrangements (e.g., episodic care, etc.) and opportunities for waiver of the 3-day
prior hospital stay requirement in Medicare bundled payment and accountable care
arrangements unless they have at least a 3-Star overall rating. Such a facility may be unable to
receive sufficient numbers of admission referrals and Medicare/Medicaid payments.
In summary, inaccurate MDS assessments can lead to inaccurate billing, poor outcomes
and declining referrals, and ultimately threaten business sustainability. LeadingAge NY
Technology Solutions provides a suite of tools that help members enhance quality, MDS
accuracy and ultimately reimbursement. The newest tool, Quality Apex, has an MDS 3.0
“ Scrubber” with over 275 audits providing an opportunity to enhance each MDS’s accuracy
prior to care planning, billing or establishing QM rates.
39
Adviser a publication of LeadingAge New York | Fall 2017