OIG: Medicare overpaying for bogus support-surface claims by ProQuest


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									 NEWS | Payment & Policy

                   The Payment Expert
                                                 OIG: Medicare overpaying for
                   Patricia Boyer,
                   MSM, NHA, RN
                   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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