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LEADINGAGE NEW YORK TECHNOLOGY SOLUTIONS

THE BUILDING BLOCKS TO FINANCIAL SUCCESS

Susan Chenail, RN, CCM, RAC-CT, Senior QI Analyst

Dan Heim, Executive Vice President

Todays Objectives

•Define operations

• Importance of accuracy

•Case Study

• The implications of “getting it wrong”

•Background on Technology Solutions

• Introduce Quality Apex

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Fueling the Engine

MDS

RUGs

Quality Measures

Care Planning

Admission

From Referral to

Discharge

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Discharge

Referral

Complex Relationships

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Quality Measures

66 MC RUGs/

53 MA RUGs

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Five-Star

Pressure Injuries

Activities of Daily Living

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16 9

4

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Complex Calculations

• The risk-adjusted QM score can be thought of as an estimate

of what the nursing facility's QM rate would be if the facility

had residents with average risk.

• The adjusted four-quarter QM values for each of the MDS-

based QMs used in the five-star algorithm are computed as

follows:

• CMS calculates case-mix adjusted hours per resident day for

each facility for each staff type using this formula:

Worst Case ScenarioClaim inaccuracies

Penalties

Audits

Census and revenue

disruption

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MDS inconsistencies

Poor Care

Plan

Poor Survey

Penalties

Five-Star Rating

declines

Referrals decline

Billing inaccuracies

Audit Issues

FurtherPenalties

Poor Staffingretention

Poor Satisfaction

Surveys

Census Crash

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CCASE STUDY

Pressure Injuries

John Smitha short-stay

resident

Acute Stroke

Right Hemiparalysis

Aspiration Pneumonia

Stage 2 Pressure Injury

Atrial Fibrillation

Diabetes Mellitus

Focus Pressure Injuries:

Prevention

Early Detection

Appropriate treatment

Identifying Ulcers as New or Worsened

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Prevention

Assessment

Documentation

Care planning

Implementation

Evaluation

Early Detection

Assessment

Documentation

Care planning

Implementation

Evaluation

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Appropriate Treatment

Assessment

Documentation

Care planning

Implementation

Evaluation

Identifying Ulcers as New or Worsened

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And communicate as a team! From an actual facility SOD:During an interview with the attending physician, Medical Director, on

12/20/2016 at 12:30 PM, she stated when a resident developed a pressure ulcer

she expected to be notified for a treatment order. She stated she would expect

to be notified immediately if a Stage II pressure ulcer was not improving within 2

weeks of treatment or, if it progressed or worsened. The physician stated she

was "shocked" when she was not notified about the resident's deteriorating

pressure ulcer.

F314: Give residents proper treatment to prevent new bed (pressure) sores or

heal existing bed sores.

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What do I know about Mr. Smith?

Short-stay

Pressure Injury prior to

admission

Should not be in the

Quality Measure

At risk for new injuries

At risk for worsening

QIESNursing

Home

Compare

I wish there was

an easier way

What don’t I know about Mr. Smith?

When his MDS will be used

by CMS in the publicly

reported data

If he is in the numerator

for this measure

Whether the rate is near a

cut point to gain or lose

points

The QAPI goal for this

measure

Nursing

Home

Compare

QIES

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Effect on Quality Outcomes

Getting it wrong

• Inaccurate QM Rate

• Lost points QM Domain

• In the 75th percentile

• Survey findings

• Five-Star Rating declines

Getting it right

• QM Rate accurate

• Guides QAPI

• Improved practice patterns

• Satisfied Customers

• Five-Star Rating protected

Declining Five-Star Rating

From a

4 Star To a 1

Star

From a

3 Star

To a 1

Star

4 x the

benchmark

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Effect on Financial OutcomesGetting it wrong

LE2 vs LB1 = 32%

• Inaccurate claim over paid

• Susceptible to audit

• Retro recovery of payment/interest/fines

• Direct cost of CMPs and other remedies

• Negative impact on referrals

• Loss of points on NH Quality Initiative

• Inaccurate claim under paid

• Mismatch of income and expense

• Business unsustainable

Getting it right

LB1vs LE2 = 32%

• Fewer claim adjustments and audits

• Budget predictability

• Proper match of income and expense

• Corporate integrity

• Preferred status with payers and

networks

• Business sustainability

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1. Consumers: Initially to provide consumers and families with informed decisions regarding choice of NHs

2. Regulators: CON approval for lending and new construction can be affected by star ratings

3. Providers: Ratings used by hospitals and practitioners for referral decisions

4. Insurers: Medicare Advantage plans and hospitals participating in bundles will not refer to SNFs rated below 3 Stars. MLTC plans are narrowing networks based in part on ratings below 3 Stars

5. Accountable Care Organizations (ACOs): 3-day hospital stay waiver will not be given to SNFs rated below 3 Stars

6. Lenders and investors: HUD is now using star ratings as a component of its risk assessments

Growing Importance of Nursing

Home Five-Star Ratings

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5-Star Rating Potential Implications

• Loss of managed care business

✓MLTC network narrowing

✓Medicare Advantage and SNP agreements

✓VBP opportunities

• Loss of SNF 3-Day Rule Waiver

✓For CJR

✓For ACO arrangements

Federal Medicare

Fraud Laws

The False Claim Act

The Civil Monetary

Penalty Law

The Anti-Kickback Statute

The Physician Self-Referral

Act

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Effect on Regulatory Outcomes

Getting it wrong

• Inaccurate care plan for resident

• Pressure Injury worsens

• Bad survey outcome (e.g., actual

harm, immediate jeopardy)

• Fines/penalties

• Case mix and staffing inequity

• Incorrect risk adjustments to QMs

• Five-Star Rating declines

Getting it right

• Care Plan accurate

• Pressure Injury heals

• No Deficiencies

• No fines/penalties

• Case mix and staffing equitable

• Proper risk adjustments to QMs

• Five-Star Rating maintained or

improved

NURSING HOME FINES IN THE U.S.

NY Amount

Just over

$1 Million

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Knowing

Understanding

Improving

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TECHNOLOGY SOLUTIONS

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A Suite of Tools

Quality Metrics

Five-Star

Quality Apex

1. How does my facility

compare to other

facilities based on

quality data?

2. Where can I target

resources to improve?

3. Who are the residents

triggering the

measure?

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Seek Balance With Accuracy

Over

Coding

Under

Coding

Clinical Inequity

Inaccurate costing

Inadequate payment

Inadequate risk

adjustment

Stability of SNF

Staffing Reductions

Scrutiny

Future Compliance

Corporate Integrity

Payment liability

Understated staffing

Fraud and Abuse Those facilities that have access to MDS

data accuracy and monitoring tools will

get it right and keep it right

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Logic Message RUGIII RUGIV Resident Interview

Staff Assessment

CAA

M0150=0 and M0210=1

Resident is not at risk of developing pressure ulcers, yet has an unhealed stage 1 or higher pressure injury.

False False False False 16

M0800B>0 and (M0800B<=M0300C1)

If resident is a Short Stay resident (<=100 days in the facility), they will flag the Quality Measure: Percent of residents with Pressure Ulcers new or worsened. Review the history of each pressure injury to verify it is new or worsened as compared to the coding on the previous MDS.

True True False False 12,16

Accuracy

with

MDS Scrubber

M0210=1 and M1200Z=1

Resident has a stage 1 or higher pressure ulcer but did not receive any skin treatment.

True True False False

Worst Case ScenarioClaim inaccuracies

Penalties

Fraud

Corporate Compliance

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MDS inconsistencies

Poor Care

Plan

Poor Survey

Penalties

Five-Star Rating

declines

Referrals decline

Billing inaccuracies

Medicare Fraud

FurtherPenalties

Poor Staffingretention

Poor Satisfaction

Surveys

Census Crash

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Technology Solutions

Accurate MDS

Accurate Billing

Well Staffed

Happy Residents

Financial Well-being

31Accurate MDS

Comprehensive Care Plan

Deficiency Free Survey

No Penalties

Five-Star Rating Improves

Referrals Increase

Accurate Billing

Corporate Compliance

No Claims Recovery

Staffing retention

SuperbSatisfaction Surveys

MaximumCensus

What can Technology Solutions do

today?

Accuracy, calculation,

reporting solved

Now facilities can focus

on Resident Centered

care, running their

business and creating a

work environment that

nurtures staff retention

and customer satisfaction

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What don’t I know about Mr. Smith?

When his MDS will be used

by CMS in the publicly

reported data

If he is in the numerator

for this measure

Whether the rate is near a

cut point to gain or lose

points

The QAPI goal for this

measure

Nursing

Home

Compare

QIES

Live DemoQuality Apex

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https://app.qualityapex.com/mds/qualitymeasures/dashboard

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Questions?

Contact information:

Quality Metrics, NH Trend Report or Five-Starqualitymetrics@leadingageny.org

Quality Apexcontact@qualityapex.com

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CRESOURCES

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The federal SNF/NF Requirements of Participation are found at 42 CFR 483 Subpart B.

Additional guidance can be found in the State Operations Manual, Appendix P and PP.

CMS Transmittal regarding Episode Payment Model Operations

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2017Downloads/R169DEMO.pdf

OIG Report Adverse Events in skilled Nursing Facilities

https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf

RUGs IV Cheat Sheet

https://www.adldata.org/wp-content/uploads/2015/06/RUG-IV_Cheat_Sheet.pdf

RUGs IV Calculation Work Sheet

http://www.khca.org/files/2013/06/RUG-IVCalculationWorksheet_10_12_10fnlCJ.pdf37

CMS Compliance Group Blog re SNF care and discharge planning

http://cmscompliancegroup.com/2013/03/01/01-oig-care-discharge-planning/

DHHS OIG Report on SNF’s Care and Discharge Planning

https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf

US DOJ News Justice Department Recovers Over $4.7 Billion From False Claims Act Cases in

FY 2016

https://www.justice.gov/opa/pr/justice-department-recovers-over-47-billion-false-claims-

act-cases-fiscal-year-2016

A New Practitioner’s Guide to the Federal False Claims Act

http://www.americanbar.org/content/dam/aba/administrative/litigation/materials/sac_20

12/25-1_fca_101_presentation.authcheckdam.pdf

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Quality Improvement Organization

http://qio.ipro.org/nursing-homes-hac/clinical-topics-tools-resources/pressure-ulcer-clinical-

tools-resources

Special Focus Facilities Initiative

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/CertificationandComplianc/downloads/sfflist.pdf

CMS FY 2015 MDS Focused Survey Summary

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-06.pdf

http://www.michigan.gov/documents/lara/Nursing_Homes_Licensing_Report_CY_2016_554561_7.pdf

DataPoint: Top 10 Nursing Home Deficiencies, LeadingAge NY

https://www.leadingageny.org/topics/data/datapoints-archive/datapoint-top-10-nursing-home-

deficiencies2/

Office of Inspector General State Enforcement Actions

https://oig.hhs.gov/fraud/enforcement/state/index.Asp

DOJ Documents and Resources from the July 13, 2017 Press Conference

https://www.justice.gov/opa/documents-and-resources-july-13-2017-national-health-care-fraud-

takedown-press-conference