Post on 17-Mar-2020
8/22/2017
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LEADINGAGE NEW YORK TECHNOLOGY SOLUTIONS
THE BUILDING BLOCKS TO FINANCIAL SUCCESS
Susan Chenail, RN, CCM, RAC-CT, Senior QI Analyst
Dan Heim, Executive Vice President
Todays Objectives
•Define operations
• Importance of accuracy
•Case Study
• The implications of “getting it wrong”
•Background on Technology Solutions
• Introduce Quality Apex
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Fueling the Engine
MDS
RUGs
Quality Measures
Care Planning
Admission
From Referral to
Discharge
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Discharge
Referral
Complex Relationships
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Quality Measures
66 MC RUGs/
53 MA RUGs
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Five-Star
Pressure Injuries
Activities of Daily Living
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16 9
4
4
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Complex Calculations
• The risk-adjusted QM score can be thought of as an estimate
of what the nursing facility's QM rate would be if the facility
had residents with average risk.
• The adjusted four-quarter QM values for each of the MDS-
based QMs used in the five-star algorithm are computed as
follows:
• CMS calculates case-mix adjusted hours per resident day for
each facility for each staff type using this formula:
Worst Case ScenarioClaim inaccuracies
Penalties
Audits
Census and revenue
disruption
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MDS inconsistencies
Poor Care
Plan
Poor Survey
Penalties
Five-Star Rating
declines
Referrals decline
Billing inaccuracies
Audit Issues
FurtherPenalties
Poor Staffingretention
Poor Satisfaction
Surveys
Census Crash
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CCASE STUDY
Pressure Injuries
John Smitha short-stay
resident
Acute Stroke
Right Hemiparalysis
Aspiration Pneumonia
Stage 2 Pressure Injury
Atrial Fibrillation
Diabetes Mellitus
Focus Pressure Injuries:
Prevention
Early Detection
Appropriate treatment
Identifying Ulcers as New or Worsened
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Prevention
Assessment
Documentation
Care planning
Implementation
Evaluation
Early Detection
Assessment
Documentation
Care planning
Implementation
Evaluation
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Appropriate Treatment
Assessment
Documentation
Care planning
Implementation
Evaluation
Identifying Ulcers as New or Worsened
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And communicate as a team! From an actual facility SOD:During an interview with the attending physician, Medical Director, on
12/20/2016 at 12:30 PM, she stated when a resident developed a pressure ulcer
she expected to be notified for a treatment order. She stated she would expect
to be notified immediately if a Stage II pressure ulcer was not improving within 2
weeks of treatment or, if it progressed or worsened. The physician stated she
was "shocked" when she was not notified about the resident's deteriorating
pressure ulcer.
F314: Give residents proper treatment to prevent new bed (pressure) sores or
heal existing bed sores.
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What do I know about Mr. Smith?
Short-stay
Pressure Injury prior to
admission
Should not be in the
Quality Measure
At risk for new injuries
At risk for worsening
QIESNursing
Home
Compare
I wish there was
an easier way
What don’t I know about Mr. Smith?
When his MDS will be used
by CMS in the publicly
reported data
If he is in the numerator
for this measure
Whether the rate is near a
cut point to gain or lose
points
The QAPI goal for this
measure
Nursing
Home
Compare
QIES
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Effect on Quality Outcomes
Getting it wrong
• Inaccurate QM Rate
• Lost points QM Domain
• In the 75th percentile
• Survey findings
• Five-Star Rating declines
Getting it right
• QM Rate accurate
• Guides QAPI
• Improved practice patterns
• Satisfied Customers
• Five-Star Rating protected
Declining Five-Star Rating
From a
4 Star To a 1
Star
From a
3 Star
To a 1
Star
4 x the
benchmark
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Effect on Financial OutcomesGetting it wrong
LE2 vs LB1 = 32%
• Inaccurate claim over paid
• Susceptible to audit
• Retro recovery of payment/interest/fines
• Direct cost of CMPs and other remedies
• Negative impact on referrals
• Loss of points on NH Quality Initiative
• Inaccurate claim under paid
• Mismatch of income and expense
• Business unsustainable
Getting it right
LB1vs LE2 = 32%
• Fewer claim adjustments and audits
• Budget predictability
• Proper match of income and expense
• Corporate integrity
• Preferred status with payers and
networks
• Business sustainability
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1. Consumers: Initially to provide consumers and families with informed decisions regarding choice of NHs
2. Regulators: CON approval for lending and new construction can be affected by star ratings
3. Providers: Ratings used by hospitals and practitioners for referral decisions
4. Insurers: Medicare Advantage plans and hospitals participating in bundles will not refer to SNFs rated below 3 Stars. MLTC plans are narrowing networks based in part on ratings below 3 Stars
5. Accountable Care Organizations (ACOs): 3-day hospital stay waiver will not be given to SNFs rated below 3 Stars
6. Lenders and investors: HUD is now using star ratings as a component of its risk assessments
Growing Importance of Nursing
Home Five-Star Ratings
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5-Star Rating Potential Implications
• Loss of managed care business
✓MLTC network narrowing
✓Medicare Advantage and SNP agreements
✓VBP opportunities
• Loss of SNF 3-Day Rule Waiver
✓For CJR
✓For ACO arrangements
Federal Medicare
Fraud Laws
The False Claim Act
The Civil Monetary
Penalty Law
The Anti-Kickback Statute
The Physician Self-Referral
Act
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Effect on Regulatory Outcomes
Getting it wrong
• Inaccurate care plan for resident
• Pressure Injury worsens
• Bad survey outcome (e.g., actual
harm, immediate jeopardy)
• Fines/penalties
• Case mix and staffing inequity
• Incorrect risk adjustments to QMs
• Five-Star Rating declines
Getting it right
• Care Plan accurate
• Pressure Injury heals
• No Deficiencies
• No fines/penalties
• Case mix and staffing equitable
• Proper risk adjustments to QMs
• Five-Star Rating maintained or
improved
NURSING HOME FINES IN THE U.S.
NY Amount
Just over
$1 Million
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Knowing
Understanding
Improving
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TECHNOLOGY SOLUTIONS
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A Suite of Tools
Quality Metrics
Five-Star
Quality Apex
1. How does my facility
compare to other
facilities based on
quality data?
2. Where can I target
resources to improve?
3. Who are the residents
triggering the
measure?
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Seek Balance With Accuracy
Over
Coding
Under
Coding
Clinical Inequity
Inaccurate costing
Inadequate payment
Inadequate risk
adjustment
Stability of SNF
Staffing Reductions
Scrutiny
Future Compliance
Corporate Integrity
Payment liability
Understated staffing
Fraud and Abuse Those facilities that have access to MDS
data accuracy and monitoring tools will
get it right and keep it right
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Logic Message RUGIII RUGIV Resident Interview
Staff Assessment
CAA
M0150=0 and M0210=1
Resident is not at risk of developing pressure ulcers, yet has an unhealed stage 1 or higher pressure injury.
False False False False 16
M0800B>0 and (M0800B<=M0300C1)
If resident is a Short Stay resident (<=100 days in the facility), they will flag the Quality Measure: Percent of residents with Pressure Ulcers new or worsened. Review the history of each pressure injury to verify it is new or worsened as compared to the coding on the previous MDS.
True True False False 12,16
Accuracy
with
MDS Scrubber
M0210=1 and M1200Z=1
Resident has a stage 1 or higher pressure ulcer but did not receive any skin treatment.
True True False False
Worst Case ScenarioClaim inaccuracies
Penalties
Fraud
Corporate Compliance
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MDS inconsistencies
Poor Care
Plan
Poor Survey
Penalties
Five-Star Rating
declines
Referrals decline
Billing inaccuracies
Medicare Fraud
FurtherPenalties
Poor Staffingretention
Poor Satisfaction
Surveys
Census Crash
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Technology Solutions
Accurate MDS
Accurate Billing
Well Staffed
Happy Residents
Financial Well-being
31Accurate MDS
Comprehensive Care Plan
Deficiency Free Survey
No Penalties
Five-Star Rating Improves
Referrals Increase
Accurate Billing
Corporate Compliance
No Claims Recovery
Staffing retention
SuperbSatisfaction Surveys
MaximumCensus
What can Technology Solutions do
today?
Accuracy, calculation,
reporting solved
Now facilities can focus
on Resident Centered
care, running their
business and creating a
work environment that
nurtures staff retention
and customer satisfaction
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What don’t I know about Mr. Smith?
When his MDS will be used
by CMS in the publicly
reported data
If he is in the numerator
for this measure
Whether the rate is near a
cut point to gain or lose
points
The QAPI goal for this
measure
Nursing
Home
Compare
QIES
Live DemoQuality Apex
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https://app.qualityapex.com/mds/qualitymeasures/dashboard
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Questions?
Contact information:
Quality Metrics, NH Trend Report or Five-Starqualitymetrics@leadingageny.org
Quality Apexcontact@qualityapex.com
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CRESOURCES
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The federal SNF/NF Requirements of Participation are found at 42 CFR 483 Subpart B.
Additional guidance can be found in the State Operations Manual, Appendix P and PP.
CMS Transmittal regarding Episode Payment Model Operations
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/2017Downloads/R169DEMO.pdf
OIG Report Adverse Events in skilled Nursing Facilities
https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf
RUGs IV Cheat Sheet
https://www.adldata.org/wp-content/uploads/2015/06/RUG-IV_Cheat_Sheet.pdf
RUGs IV Calculation Work Sheet
http://www.khca.org/files/2013/06/RUG-IVCalculationWorksheet_10_12_10fnlCJ.pdf37
CMS Compliance Group Blog re SNF care and discharge planning
http://cmscompliancegroup.com/2013/03/01/01-oig-care-discharge-planning/
DHHS OIG Report on SNF’s Care and Discharge Planning
https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf
US DOJ News Justice Department Recovers Over $4.7 Billion From False Claims Act Cases in
FY 2016
https://www.justice.gov/opa/pr/justice-department-recovers-over-47-billion-false-claims-
act-cases-fiscal-year-2016
A New Practitioner’s Guide to the Federal False Claims Act
http://www.americanbar.org/content/dam/aba/administrative/litigation/materials/sac_20
12/25-1_fca_101_presentation.authcheckdam.pdf
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Quality Improvement Organization
http://qio.ipro.org/nursing-homes-hac/clinical-topics-tools-resources/pressure-ulcer-clinical-
tools-resources
Special Focus Facilities Initiative
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/sfflist.pdf
CMS FY 2015 MDS Focused Survey Summary
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-06.pdf
http://www.michigan.gov/documents/lara/Nursing_Homes_Licensing_Report_CY_2016_554561_7.pdf
DataPoint: Top 10 Nursing Home Deficiencies, LeadingAge NY
https://www.leadingageny.org/topics/data/datapoints-archive/datapoint-top-10-nursing-home-
deficiencies2/
Office of Inspector General State Enforcement Actions
https://oig.hhs.gov/fraud/enforcement/state/index.Asp
DOJ Documents and Resources from the July 13, 2017 Press Conference
https://www.justice.gov/opa/documents-and-resources-july-13-2017-national-health-care-fraud-
takedown-press-conference