MDS Alert

Published on Sun Jun 17, 2012 PDF

But be proactive about going to CMS with unresolved questions.

In order to ensure that providers are getting timely responses to their questions about the MDS 3.0 and RUG IV changes, they should first contact their state RAI coordinators, Fiscal Intermediaries (FIs) or Medicare Administrative Contractors (MACs) rather than immediately contacting officials at CMS' Central Office, John Kane, health insurance specialist with CMS' Division of Institutional Post Acute Care urged during the May 24 SNF Open Door Forum.

"It is important that we re-establish the appropriate protocols for responding to provider questions that had been in place prior to the more recent SNF policy changes," Kane explained. "We understand that a lot of the policy changes have been comprehensive, complicated in certain cases, and confusing in others. So, we at Central Office have done our best to try to respond as quickly as possible to many of your questions."

"But," Kane continued, "in order to provide for more timely and consistent responses, we need to ensure that you are going through the proper channels to receive answers to your questions. Basically, if you have any questions that are related to coding of the MDS or anything related to the MDS assessments themselves, your first, primary contact should be your state RAI coordinator. They are very well trained, very well-educated and very willing and desiring to answer any questions that you have related to the assessment."

"If your RAI state coordinator is unable to answer your question for any reason," Kane noted, "then there is an RAI panel to which the state coordinator would refer your question . . . If there was an issue that the RAI panel found that there was confusion on or that they were unsure of, they would then contact us and we would be able to provide a response."

Going through your state RAI coordinators first will allow CMS to track provider questions better and ensure that you are getting a timely response, he explained. (Editor's note: A listing of State RAI coordinators and regional offices can be found at: www.cms.gov/site-search/search-results.html?q=state%20rai%20coordinators).

For questions that are related to billing or the processing of your claims, your first and best contact is your FI or MAC that is going to be reviewing those claims, Kane noted. "They are the best and most properly suited to answer these sort of questions . . . If, however, your FI or MAC is unsure of the policies or how to respond to a given question, they will refer the issue to the regional office for that area. . . Any questions that the regional office might need help with would then get referred up to Central Office."

It is important that providers address their billing questions to their FIs and MACs and not their state RAIs, Kane stressed. "Some of the state RAIs have been getting billing questions and they've been trying to provide a response, but these questions really should be directed to the FIs and the MAC contractors."

Kane admitted that these procedures will seem very bureaucratic to many providers but, he emphasized, that it is important for providers to go through these channels so that CMS Central Office can identify policy changes that may be unclear or that FIs and MACs may be unaware of. "We may need to provide additional education and training to ensure that the FIs and MACs can appropriately answer your questions."

One provider on the call expressed concern over the ability to get timely, accurate responses from his state RAI coordinator. The caller, from Tennessee, said that if providers had to go through this process to get their questions answered, they would be "facing some pretty lengthy periods of time or no answers at all" from their state RAI coordinator.

In follow-up interviews, MDS Alert has learned that many providers have had negative experiences with their state RAI coordinators. "It can be a real waste of time, because the state RAI coordinator may take weeks to get back to you, and when they do, sometimes their answers are completely off the wall," reported an industry insider.

During the forum, Kane said that it was important for providers who were having problems with a state RAI coordinator to contact Central Office. "It's important that we be made aware of these kinds of problems with state RAIs so that we can identify if it's a training or educational issue . . . it's important in these cases to establish what the causes are and what exactly is happening," he emphasized.

"Providers who are having issues with their state RAI coordinators need to become more assertive and alert CMS Central Office about their negative experiences," says Marilyn Mines, RN, RAC-CT, BC, senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill. "Follow the chain-of-command and start with your state RAI coordinator, but if you are really getting nowhere, go ahead and send CMS a letter detailing your experience," she advises. Some providers may prefer to have their Medicare consultants contact CMS on their behalf, but providers should not be afraid to do so themselves, she adds.

Helpful contacts: A listing of FIs can be found at: www.cms.gov/apps/contacts. MACs can be found at: www.cms.gov/medicare-coverage-database/indexes/contacts-part-b-medicare-administrative-contractor-index.aspx?bc=AgAAAAAAAAAA&)

Questions involving MDS technical issues should continue to be referred to the MDS tech e-mail box at: mdstechissues@cms.hhs.gov. Any questions on the SNF Open Door Forum should still go to ODF e-mail box at: SNF _LTCODF-L@cms.hhs.gov