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killed nursing facilities (SNFs) face innumerable financial and regulatory challenges on a daily basis, challenges that can make or break even the most organized facility. They must navigate a maze of increasingly complex payment systems and fluid government regulations while focusing on the accuracy of their documentation—not to mention the over-arching goal of delivering the highest level of care to their residents.
       Too often, the result of these challenges on facility staff is uncaptured reimbursements and unclear quality of care measures.
       Fortunately, there are resources to help facilities maximize reimbursement, including organizations like Zimmet Healthcare Services, LLC, a full-service support consulting firm in Morganville, NJ. In March, reimbursement analyst Kenneth Monahan presented a program on successful revenue-cycle management at the second annual conference of the American Association of Nurse Assessment Coordinators (AANAC) in Chicago, Ill. Shortly thereafter,
ECPN discussed with him ways in which facilities can maximize the effectiveness of their reimbursement programs, improve operational communication and efficiency, and maintain the integrity of Medicare and Medicaid programs. The highlights of that discussion follow in a question-and-answer format.

ECPN: What are some of the steps facilities should take during pre-admission to ensure appropriate placement of the resident?

       Monahan: We strongly advise facilities to appropriately evaluate each case as it comes in, taking a look at the medical and clinical aspects for that resident, as well as all of the financial concerns, such as what’s going to be primary, what’s going to be secondary, and how is this going to be paid for. It is important then to follow up and clarify a number of questions: Is the resident paying privately (and how long will that last)? Does he or she need to apply for Medicaid? How many days of Medicare coverage or coinsurance remain? Will Medicaid and/or Medicare cover the medical costs of the resident’s stay?
       On the other end of things, however, the facility must manage this process. One important aspect is to have a screener who goes out to where the residents are, whether it is the hospital or the residents’ homes, to screen them and make sure they’re appropriate candidates for residency in a SNF. The screener must also keep in mind whether that facility has the clinical know-how to care for that resident.

ECPN: What is most important to consider in the revenue-cycle process, from resident admission to the generation of a bill?

       Monahan: The 2 most important things to focus on are the facility’s Minimum Data Set (MDS) and UB-92 reporting form data. It is crucial to ensure that you have systems in place that are going to be able to verify the accuracy of both sets of data. Not only that, but the facility needs to have a system in place to obtain and input all of the most accurate information into those 2 documents.
       From a systems perspective, a manager in the facility should be the gatekeeper and oversee the process. That doesn’t mean he or she has to be actively involved, or hands-on, in every aspect, day to day, but the manager has to make sure that all areas of documentation in the facility are taken care of and that staff are accountable for that documentation. For instance, the pre-admission evaluation might be assigned to a screener or admission person, but it is important for the administrator to follow up and let that screener or admission person know exactly what needs to be done and know whether he or she is abreast of new changes in the processes that could affect the way he or she does his or her job. We often tell facilities that if they’re not following up, it’s not happening.
       In the nursing aspect, you could also say that if the nurses don’t document it, it didn’t happen. It’s important for facilities to maximize the payment generated from the MDS, and you need to make sure that everything that is provided for the resident in his or her care delivery is documented. If you’re administering intravenous (IV) therapies, observing patient behaviors, or seeing and treating wounds, you want to make sure it’s all documented. There must be documentation to support the care provided. Also, be sure that you are capturing all the information that the nurses are documenting.

ECPN: What other types of roles should the administrator take on to ensure accurate reimbursement?

       Monahan: Basically, administrators should oversee any type of system devised. They—or an appointee—have to follow up on these systems to ensure the processes are working. For example, you might have UB-92 reviews each month before you bill to ensure accuracy and confirm that nothing is missed during the claims. Many times, you’ll have business personnel print out the claims before they’re submitted and go over them with appropriate staff. Especially with regard to consolidated billing, you want to make sure that all of the services delivered to the resident, such as pharmacy and other ancillary billing, are on the claim.

ECPN: What is the most common roadblock to an efficient reimbursement process that you see in facilities?

       Monahan: The biggest is communication, especially with MDS and UB-92, that whole cycle. If you have certain segments or staff not in communication with one another, be it therapy and nursing or nursing and billing, there will be issues and problems that arise. When pertinent data are left off, it can result in lower resource utilization group (RUG) levels being billed or the types of documentation inconsistencies that cause billings to be denied. These are the things that negatively affect cash flow.
       Furthermore, the issue of incomplete data during the pre-admission process is another roadblock. If the facility does not have the full financial or clinical picture of a new admission, issues of appropriateness of skilled care or lost revenue due to insurance issues can arise.

ECPN: What can facilities do on the clinical side to minimize the risk of inefficient reimbursement?

       Monahan: It is crucial for the facility to make sure it is capturing everything that staff members are providing to residents. The most common thing we find in facilities is errors or omissions on the MDS, and the timing of assessment reference dates (ARDs) causes the majority of lost Medicare revenue. Understating ARD planning, or omitting IV therapy or fluids, for example, can greatly affect the reimbursement that the facility will receive. It may become a dual problem too, because most states have case mixes for Medicaid and Medicare. The problems you’re having with 1 affect the other. Usually, you have the same staff completing these forms, and you’ll therefore have a problem on both ends.

ECPN: What are some other strategies to maximize reimbursement and operational efficiency?

       Monahan: Focus on supporting documentation. Make sure that you’re capturing and documenting the skilled services and therapy provided. Not having that type of supporting documentation is a major issue with a lot of facilities. On the financial side, not enough is being captured on admission. Someone might be admitted under managed care when they’re not, or staff may fail to complete the MDS, resulting in default payment. On the back end, when there are outstanding monies, it is important to follow up to get that through accounts receivable. Lastly, many facilities are pressured to take in residents from hospitals, but they have to ensure that they have systems in place to best capture the important data when they initially admit those people.