Harmony Healthcare Blog

Case Mix Best Practices for the Skilled Nursing Facility

Posted by The Harmony Team on Thu, Mar 05, 2015

activity-based-funding_header-867191-editedIn many states, Medicaid reimbursement is already transitioning to managed care, striking fear in the hearts of most operators and administrators - and for good reason.  Providing quality care for the Medicaid population has been part of the Skilled Nursing Facility (SNF) industry for years even with per diem reimbursements far below cost.   While not always the case, managing the Medicaid population can mean potentially delayed reimbursement and lead to more administrative hoops to jump through.

In states where Case Mix is a factor in determining Medicaid reimbursement such as New York, Georgia, New Hampshire, Wisconsin and Maine just to name a few, one of the most common questions posed by administrators is:  “Why do other facilities have a better Case Mix than my facility?”

Skilled Nursing Facilities who’s Medicaid-only Case Mix accurately depicts the clinical acuity of their resident population will tell you one thing. “It’s all about attention to details.”

A Case Mix system is typically a weighted average based on a RUG system.  However, most states use a RUG system that is different than the 66 RUG system used by Medicare.  Even the best MDS coordinators constantly find themselves “changing hats” between their Medicare Part A hat and their Medicaid Case Mix hat because of different system rules and nuances.  IV fluids & meds are a great example.

The key elements to consider while managing Case Mix are:

  • Always ensure clinically-appropriate Part B

  • Execute ADL coding accuracy

  • Perfect behavior documentation

  • Encourage open communication between Nursing, Therapy and MDS

The best performing facilities also adopt a 52 week approach where Case Mix is a consideration every day.  Focusing on CMI when the Case Mix window opens and expecting success is akin to cramming the night before an exam and expecting to ace it.  Of course the last minute focus might help, but it’s unlikely to produce the optimal result.  

Additionally, Retrospective Case Mix audits performed by the States have become much more intense, with the intent to recoup payments already made.

To avoid a negative Case Mix audit finding, here are a few useful tips:

  • Pay close attention to proper MDS Completion or “Book Usage.”  Refer to the RAI manual when unclear

  • Ensure the accuracy of Payor Source when submitting the Case Mix Roster

  • Be mindful of documentation of Depression/Behaviors

  • Capturing Orders and Visits is critical for the Clinically Complex category (Coumadin, vaccines, flu shots typically should not be counted)

  • For BMI, tracking the baseline and current height and weight is critical

  • Documentation, documentation, documentation!  Auditors are looking for documentation that care was provided not just mentioned in the Care Plan

  • For Part B therapy, clear documentation of decline and audit trail of screen, order, pickup, clinically appropriate documentation are all necessary.  Putting everyone on Part B program when Case Mix window opens is asking for trouble.  Changes at beginning or during CMI window can be viewed as red flags.

  • Review, Review, Review!  Audit medical records and monitor your process.  Similar to the “levels of review” processes adopted by accounting firms, the more levels of review on your medical records, the more your process will lead to the highest level of accuracy. 

If you have questions regarding Case Mix Best Practices or need help maintaining compliance, please click here to contact Harmony Healthcare International or call us at (800) 530-4413. 

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Topics: Case Mix, Case Mix Reimbursement

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