Mock Medicaid for Case Mix States

Long-term care facilities have always been held accountable against a wide range of obligations in order to provide services to residents and receive Medicare or Medicaid reimbursement. The Affordable Care Act (ACA) introduced additional provisions aimed at preventing and reducing fraud, waste and abuse.

As a condition for participation in federal health care payment programs, long-term care facilities are now required to develop and implement an effective compliance plan and have become the target of frequent audits from various sources, including MAC, RAC and ZPIC, among the growing list. Harmony Healthcare International (HHI) has developed proprietary, comprehensive audit tools that assist with the identification and prioritization of target areas defined by the governmental agencies. These Harmony Healthcare International (HHI) audits are essential for facilities to maintain a compliant landscape and determine key educational opportunities. Case Mix (Medicaid) MMQ (Massachusetts) OMIG (New York) Detailed medical record review highlighting MDS coding accuracy related to Medicaid reimbursement. Focus areas include ADL documentation and coding, physician orders, mood indicators, wounds, pain, as well as other RUG qualifiers indicated by State System. In most states, the MDS is also the foundation of the Medicaid reimbursement methodology. It is used to classify residents into resource utilization groups (RUGs) that in turn generates a Case Mix score contributing to adjustments to the facility's Medicaid Rate. As with Medicare reimbursement, the MDS contains extensive information on the resident’s nursing needs, ADL impairments, cognitive status, behavioral problems, and medical diagnoses. Harmony Healthcare International (HHI) is available to assist the provider in understanding state specific regulations for compliant scheduling and completion of the MDS to ensure the accurate reflection of the clinical conditions and services rendered to the long term care population of the SNF.

How can Harmony Healthcare International (HHI) help?

Harmony Healthcare International (HHI) to provide a focused Medicaid Case Mix compliance review to include:

  • Review of current Medicaid Case Mix Process
  • Review of state specific Medicaid Case Mix reimbursement system and classification
  • Compliance audits for MDS Accuracy, MDS supporting documentation, therapy documentation, nursing documentation, physician certification completion, medical necessity and other needed elements to support claim integrity
  • Medicare Part B Therapy Utilization Review (PT, OT and ST)
  • ADL Coding: Supporting Documentation and MDS Accuracy
  • Case Mix Documentation Review
  • State Case Mix specific education
  • Medicare Part B Therapy Documentation Review
  • Nursing Documentation Review
  • Comprehensive Written Report
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