MDS Alert

Published on Tue Jan 27, 2004 PDF

They're here ... CMS recently released enhanced quality measures to be publicly reported as part of its Nursing Home Quality Initiative. On Jan. 22, the Centers for Medicare & Medicaid Services posted the 14 quality measures on the Nursing Home Compare Web site. The chronic-care measures are as follows:

*     Percent of residents whose need for help with daily activities has increased;
*     Percent of residents who have moderate to severe pain;
*     Percent of residents who were physically restrained;
*     Percent of residents who spent most of their time in bed or in a chair;
*     Percent of residents whose ability to move about in and around their room got worse;
*     Percent of residents with a urinary tract infection;
*     Percent of residents who have become more depressed or anxious;
*     Percent of high risk residents who have pressure sores;
*     Percent of low risk residents who have pressure sores;
*     Percent of low risk residents who lose control of their bowels or bladders;
*     Percent of residents who have/had a catheter inserted and left in their bladder;

The enhanced post-acute care measures are:

*     Percent of short stay residents who had moderate to severe pain;
*     Percent of short stay residents with delirium;
*     Percent of short stay residents with pressure sores. Editors note: See the next MDS Alert for full coverage of the new QMs.

SNFs must provide a new noncoverage notice to Medicare managed care enrollees. Starting this year, Medicare+Choice enrollees have the right to an expedited review by a quality improvement organization (QIO) when they dispute their M+C plan's decision to end coverage of services provided by skilled nursing facilities, home health agencies, and comprehensive rehabilitation facilities.
 
Thus, your SNF must provide a standardized advance notice of Medicare noncoverage (NOMNC) to M+C enrollees no later than two days before coverage of their services will end, according to an April 2003 final rule published by the Centers for Medicare & Medicaid Services. (If the resident is anticipated to stay less than two days, provide the notice at admission). The NOMNC (formerly referred to as the Important Medicare Message of NonCoverage) is a short, straightforward notice that simply informs the patient of the date that coverage of services is going to end and describes what the resident/ representative should do if he wishes to appeal the decision or needs more information. You can access the form and instructions for implementation at www.cms.hhs.gov/healthplans/appeals. If the resident or his authorized representative disagrees with the plan's decision to end his coverage, he may request an expedited review of the case by the QIO in that state. The M+C plan must furnish the resident or his authorized representative a detailed notice explaining why services are no longer necessary or covered.
 
The expedited review provisions generally require the QIO to respond within 48 hours or less of the resident's request for review. "The nursing home is at risk to provide services during that time - and the beneficiary may be responsible for the charges if the QIO review determination is unfavorable," says Marie Infante, an attorney with Mintz, Levin, Cohn, Ferris, Glovsky & Popeo in Washington. Thus, the nursing home admissions agreement should cover the issue of personal responsibility for payment after applicable third-party coverage ends, Infante suggests. 


CMS won't be recouping overpayments identified by audits of ineligible SNF stays. CMS has decided the agency can't assign blame to the beneficiary or to the SNF for part A stays that lacked a bona fide three-day prior hospital stay, according to a CMS representative speaking at a recent SNF open forum. Fiscal intermediaries that had started to recoup the funds will be notifying facilities of the decision to refrain from collections. Even so, SNFs should have a system to validate, if possible, with the hospital that a Part A admission has met the three-day qualifying stay (three consecutive overnights as an inpatient), advises Steve Jones, CPA, with the Clearwater, FL office of Moore Stephens Lovelace.