Medicare Compliance & Reimbursement

Tip: Validation reports hold the key to RAI compliance.

While reviewing validation reports, look for warning messages when assessments are late or submissions were out of sequence to nip trouble in the bud. Let the QA committee become your ally.

Best practice: The MDS nurse can take the validation reports from the state system to the quality assurance committee. The QA committee can double check to make sure all MDSs transmitted were accepted by the state repository, and review warning messages with an eye for identifying problematic patterns of errors.

Don’t Be Late for Important Dates

For example, the QA committee should identify late assessments, which can cause survey problems.

The validation report will let you know about late assessments in several ways. For example, you will get a warning message if an assessment was more than 92 days from the quarterly assessment or over 366 days for the annual. You will also get a warning message if staff transmits the MDS more than 31 days from the completion date.

Nip the root cause before it buds into big trouble: When analyzing warning messages involving late MDSs, you must figure out the underlying cause. For example, some facilities discovered the MDS nurse wasn’t submitting MDSs or was doing so sporadically. And the FIs can detect that now as they are supposed to pull the corresponding MDS off their computer system for claims review.

Stay on Top of Sequencing Issues

Also look for warning messages showing out-of-sequence submissions. The MDSs and tracking forms have to flow correctly or the computer looking at the logic of the sequence can’t understand it, which generates a warning message.

You will get a warning message, for example, if you transmit the first MDS before a reentry tracking form — or a discharge tracking form before the last MDS.

Important: Make sure the team didn’t miss any MDS assessments as the cause of a warning message about out-of-sequence assessments.

Beware Medicaid woes: A number of states won’t accept assessments for Medicaid payment purposes if the assessments are out of sequence.

Solution: If you submitted the discharge or reentry tracking form prematurely, inactivate it if the sequencing problem creates a Medicaid reimbursement issue. The facility has seven days after the resident’s discharge to submit the tracking form. So the MDS team should use whatever they need of those seven days to complete and submit the MDS, and then submit the tracking form.

Troubleshooting tips: If the facility has a lot of sequencing issues, the software may not be doing some of the checking that it should be doing. Or the MDS team members’ organizational skills may need a tune-up so they can submit assessments in the right order. For example, multiple people may be submitting the files at different rates of speed.

Another potential problem: The MDS nurse may be submitting the assessments too quickly. The nurse should certainly strive to submit as often as she can.

But there’s a point where she might need to back off just a little to ensure you have records coming in the right order. For example, you can get out of sequence if you’re waiting for a signature on one assessment and inadvertently submit the next MDS.

Great organization tip: To submit tracking forms and MDS in sequence, keep a log of submissions and don’t include a discharge and reentry for the same resident in the same batch.