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NEWS | Payment & Policy Ask The Payment Expert OIG: Medicare overpaying for Patricia Boyer, MSM, NHA, RN President, Boyer & Associates, LLC bogus support-surface claims By Brett Bakshis When should we start training our About 86% of Medicare staff for the new MDS 3.0 and RUGs claims for certain support IV systems? surfaces used to treat and prevent pressure ulcers did The ﬁnal MDS 3.0 is due to be published not meet coverage criteria in next month. As soon as that is available, the first half of 2007. That you should begin training your staff. The resulted in millions of dollars changes are signiﬁcant from the MDS in overpayments during that Photo: iStockphoto 2.0 and your staff can begin to imple- period, according to a new ment some of the standardized tools report from the Department now. That will assist them in the transi- of Health and Human Ser- tion to the MDS 3.0. vices Ofﬁce of the Inspector Many wound care-related claims fail to meet federal rules, an investi- Some of the tools included are the General. gation by the HHS Ofﬁce of the Inspector General recently found. PHQ-9 for depression, the CAM for In all, Medicare overpaid delirium and the PUSH tool for skin. All for “Group 2” support ser- 22% of the claims for Group program safeguard activities of these can help support your coding vices by roughly $33 million, 2 support surfaces were not are not sufficient and that today. In addition, you will see a shift according to the OIG report. medically necessary, accord- additional steps are needed from Resident Assessment Protocols Multiple types of errors ing to the OIG, with some to reduce the high error rate (RAPs) to Care Area Triggers (CATs). were made in processing the claims showing that wounds for Group 2 support surface The difference between the CATs claims, authors said. had either already healed or claims, the report found. and the RAPs is that the RAPs give you A total of 80% of claims had not presented yet at the The OIG recommends addi- speciﬁc guidelines you must follow. did not meet coverage crite- time of the claim. tional pre- and post-payment The CATs give you a list of resources ria, while 38% of claims were Taken together, the results reviews, continued education to choose from to work your CATs. You undocumented. As many as show that CMS’s current and closer monitoring. ■ as a long-term care facility need to determine what resource you want to use and then develop your own process internally. This could present some SNFs don’t like new math Goﬁgure challenges for you and your employees. At the same time that your staff is learning the new MDS 3.0, they also need to learn the new RUGs IV system. By James M. Berklan Providers say they are being unfairly punished by federal & Medicaid Services said it is recalibrating case man- agement indexes because it 6 If a proposed 2.2% Medicare market-bas-
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