Compliance is a Bad Thing?

Compliance often connotates a negative for many LTC providers. Nursing homes and other LTC facilities are deluged with a plethora of regulations. Providers face serious consequences if they are not compliant.

Currently, nursing homes are being scrutinized for a perceived uptick in reimbursement errors. This past June CMS issued notification of a 5 -claim audit related to the Patient Driven Payment Model (PDPM) for all nursing homes. This is due to a result of improper payments of claims which almost doubled from 2021 claims to a significant 15% in 2022.

The Minimum Data Set (MDS) utilized in conjunction with PDPM is a standardized assessment tool used with all residents in a CMS Medicare or Medicaid certified facility. The MDS contains extensive information on residents nursing care needs. The MDS is a comprehensive assessment and impacts an organizations reimbursement, compliance, and care quality. CMS mandates that all nursing facilities routinely and accurately administer the Minimum Data Set (MDS).

Misinterpreting, submitting inaccurate information, demonstrating insufficient or missing documentation or delinquent submission of the MDS all are considered non- compliant behaviors and place a facility at substantial risk.

The new MDS 3.0 changes that commenced on October 1 are significant and certainly add to the challenges of accurately completing the MDS.

The MDS is only one aspect of the whole reimbursement picture.

A comprehensive reimbursement review must look at areas such as admissions the front- end process, claims submission, third party reimbursement accuracies and more. Just because reimbursement is coming through the door does not ensure that that reimbursement is optimized nor is it a given that you have the compliance needed to keep that reimbursement.

Identifying reimbursement compliance risk needs to be part of an overall comprehensive compliance program that should be in place for all organizations. It is imperative that organizations develop a hardwired routine for internal and external audits for areas like reimbursement to identify areas of risk. Leaders who consciously focus on improving workforce culture realize that implementing efficient, beneficial processes while ensuring needed resources for staff will ultimately lead to improved productivity, improved resident care, optimized reimbursement and yes, compliance.

Compliance is necessary. It’s only a bad thing when you don’t have it.

Microscope can provide expert consulting for many areas of compliance:

• Comprehensive Compliance Program
• Comprehensive Reimbursement Review
• MDS Review
• Regulatory Education
• Revenue Cycle Management
• Cost Reporting
• Emergency Preparedness

For more informaiton, please contact: 

Michael F. Masse, OTR/L- Senior Director, Continuing Long-term Care