Note: Since publishing this article, ODM has finalized its decision to use the RUG-IV, 57 group model for establishing Medicaid case mix scores for December 2015 quarterly case mix scores and going forward. These case mix scores will impact Ohio skilled nursing facilities’ Medicaid rates effective 7/1/2016.
Ohio Department of Medicaid (ODM) is in the process of moving to RUG-IV for the Medicaid resident classification system. As of this writing, it is uncertain which model Ohio will use: 48 groups, 57 groups or 66 groups. Regardless of the grouper selected, there are substantial differences between how scores are calculated under RUG-IV and RUG-III including changes to:
- Case mix weights
- ADL End Splits
- Hierarchy orders
- Elimination of hospital look backs
For a glimpse at what could occur if your facility is not prepared, take a look at what happened to statewide average quarterly scores after the last major case mix transition from MDS 2.0 to MDS 3.0 on October 1, 2010:
Facilities were so unprepared for this change that Medicaid ultimately agreed to disregard the 12/31/10 and 3/31/11 scores in the calculation 7/1/11 Medicaid rates. There are no guarantees that Medicaid would again consider disregarding a quarterly score, so you cannot afford to be unprepared.
What can you do to ensure your facility is prepared?
At this time, ODM is providing the RUG- IV Hierarchical Provider Frequency Distribution Report for quarter ending June 30, 2015 so all facilities can see what effect RUG-IV will have on the classification of your residents. Most likely, it is your business office manager that has access to these reports in your Provider Mailbox. It is imperative that they pull these reports as soon as possible and get them to your MDS nurse for analysis to ensure that you get credit for all the care you are delivering to your residents. Otherwise, your Medicaid rate could be negatively impacted. Please forward your reports to us so that we can help with this analysis.
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Are you in the process of preparing your 2016 budgets? If yes, estimating your July 1 Ohio Medicaid rate is not as easy as in prior years.
Under Medicaid pricing, it has been relatively easy to get a reasonable estimate of your July 1 Medicaid rate. However, this year is not as simple as we still have many unknowns: final rebased prices, determination of RUG-IV grouper (48, 57 or 66), quality thresholds, etc. We are currently evaluating the data and still don’t know the specifics of how each case mix grouper will impact an individual facility. Because of the significant variance in case mix weights across the various RUG-IV categories, we could see very disparate impacts on provider rates when the rebasing is completed. Based on an early look at the data, facilities with a significant number of Extensive Services (ES) patients could see a significant bump in their rates, while some facilities with lower acuity residents could see a pretty big decrease. If you provide your RUG- IV Hierarchical Provider Frequency Distribution Report from ODM, then we can help with your estimated Medicaid rates.
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Do you need help budgeting 2016 expenses? If yes, as always the HW&Co. benchmarking report can help.
Our NF and ICF-IID Benchmarking Reports provide a comprehensive overview of your facility’s expenses, census, and staffing patterns that is presented in a format that provides for an easy comparison to your competitors and peers. This feature makes the HW&Co. Benchmarking Report an integral starting point for strategic planning and budgeting sessions. The reports, prepared from the 2014 Ohio Department of Medicaid (ODM) and Department of Developmental Disabilities (DODD) cost report databases, contain detailed analyses of 2014 expenses, census, and staffing data for your facility combined with a comparative analysis of selected competitors, county, peer group and statewide averages. These reports provide a unique value-added service for our clients.
Please contact a HW Healthcare Advisor if you are interested in help with your budgeting process.
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Do you have all the proper ICD-10 diagnosis codes in your nursing and billing records for October claims? If not, your claims will be rejected and cash flow interrupted.
All claims with dates of service on or after October 1, 2015 must be submitted using ICD-10 diagnosis codes. Claims with dates of service prior to October 1, 2015, must continue to be submitted with the appropriate ICD-9 codes. As a quick check, ICD-10 codes begin with a letter and are up to 7 digits long compared to the ICD-9 codes which were up to 5 numeric digits long, with some V and E codes. PointClickCare users can click here for more detail of what is needed in your system. It is important to ensure that both your nursing and billing departments have updated all necessary fields so that your October claims are not rejected.
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