Medicaid Rates
Case-Mix Errors
Resident Satisfaction Survey
With the passage of Amended Substitute House Bill 1 (ASHB1), the Legislature continued the transition to the pricing system for nursing facilities. The bill included a number of noteworthy changes, including an increase in the Franchise Permit Fee and the introduction of a “Consolidated Services Payment” (“bundling”) for certain services that were previously directly billed to the Ohio Department of Job and Family Services (ODJFS) by the service provider.
The bill also included a change in the stop gain/loss methodology to no longer limit a facility’s rate changes once the facility is “in price.” This could lead to significant changes in rates if case mix scores change. We estimate that 40% of providers will be “in price” as of July 1, 2010. For those facilities not yet “in price,” the rate changes will be limited to a 2.25% increase or a 1% decrease for fiscal year 2011.
The “bundling” provisions of ASHB1 will remain in effect for the coming fiscal year. As a reminder, the “Consolidated Services Payment” covers therapies, transportation, oxygen, wheelchairs and certain over-the-counter drugs. For fiscal year 2011, the “bundling” add-on will be $3.91 plus any additional amount to cover potential Franchise Permit Fee increases. There are a number of major operational issues created by the “bundling” provisions. We have many resources available to assist you with any questions you may have regarding “bundling.”
As ODJFS continues its transition to the pricing system, the change in the stop gain/loss methodology mentioned above has created opportunities to potentially increase reimbursement if a Change of Provider (CHOP) agreement is properly timed. Likewise, improper timing of a CHOP could lead to a significant decrease in reimbursement. Please contact us if you have questions or are considering a change of provider.
CASE-MIX ERRORS AFFECTING REIMBURSEMENT
As the Medicaid payment system transitions to a pricing system (see “Nursing Facility Medicaid Rate Updates” article), an increasing number of providers will begin to see their rates directly affected by changes in “Medicaid-only” case mix scores. Therefore, providers must be diligent in reviewing their quarterly case mix reports to ensure that all residents are properly scored. We have seen a recent growing trend in nursing facilities missing out on reimbursement due to errors on these reports.
We recommend the clinical and financial teams meet quarterly to reconcile the reports to the actual census. The teams should verify that all social security numbers and recently approved Medicaid residents appear on the report. If a case mix assessment was completed prior to the date the resident was approved with an active level of care, the resident’s case mix score could potentially be disregarded. For those facilities “in price,” any change in case mix score will result in a change in the facility’s Medicaid rate. If high acuity residents are not included in the calculation, the facility will not receive the reimbursement it rightfully deserves.
We have included a flow chart on tips your clinical team can use to investigate problems with the preliminary case-mix report. Please contact us for more information on additional tools available to business office and clinical staff to assist with case-mix assessments and reviewing the quarterly reports.
Earlier this year, the Ohio Department of Aging released its bi-annual Resident Satisfaction Survey results. The statewide average score, which sets the benchmark for one of the eight quality add-on points, was 85.85%. Congratulations to the 506 facilities that scored above the statewide average! A link to the list of facility scores is available on the Ohio Long-Term Care Consumer Guide website.