Nursing Facility Case Mix Rate Setting and Audit Services
Our work with nursing facility rate setting, case mix reimbursement systems, minimum data set (MDS) data collection and reporting, and resource utilization group (RUG) classifications systems, dates back to when the Centers for Medicare & Medicaid Services (CMS) first introduced the MDS as the resident assessment instrument (RAI) for nursing facilities and worked with states during the case mix demonstration project in the late 1980s. Since then, Myers and Stauffer has worked with more than 35 states to provide nursing facility case mix rate setting and audit services.
We have also worked with more than a dozen Medicaid programs to develop and implement a comprehensive MDS record collection and review protocol that has included analysis of MDS elements and scoring, development of MDS review tools, an electronic review system, supportive documentation guidelines, sanction remedies, an appeal process, and fiscal analysis. We further support these engagements with subject matter education and training for both state and provider personnel.
We have worked closely with state Medicaid agencies to not only set but also examine reimbursement through review of medical record information used to set payment rates. We have a deep understanding of the key operational and administrative components of nursing facility reimbursement, and we know how to leverage those components to meet critical policy objectives while also assuring transparency in process and accuracy and reasonableness of rates. We are a client focused, data driven, value oriented team of experts who are actively engaged in the environmental and regulatory challenges faced by our clients.
We provide the following services:
Audit and Attest
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 Bob Hicks, CPA |
Myers and Stauffer has been performing cost report attest work for clients since the firm’s inception. Our cost report audit team has developed cost report databases, status logs, and rate setting systems to support our clients desire to set reasonable reimbursement rates based on validated cost data. We also recognize that our clients want to appropriately focus their oversight dollars in areas that have the potential for the greatest impact, therefore we focus our efforts through a thorough risk assessment process. Our services include:
- Cost report collection.
- Web-based submission and communication system design (web-based portal) for cost report and documentation.
- Cost report database management and analytics.
- Audit and attest work on cost report data, including 2540 and Medicaid-specific cost reporting tools.
- Claims audits.
- Allowable cost verification in accordance with state and federal definitions.
- Risk assessments to target audit work.
- Training client or provider on cost report or audit issues.
- Developing cost report tools to assist clients in gathering necessary information.
Rate Setting and Reimbursement
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 John Dresslar, CPA |
As a trusted partner to more than two dozen state agency clients across the county in the area of nursing facility rate setting, we are a national expert in case mix rate setting. Our work includes long term care facilities, swing bed facilities, institutions for mental disease (IMD), and the Veteran’s Affairs Administration among others. We work closely with our clients to meet their goals and objectives in establishing their reimbursement methodology and our services include the following:
- Cost report:
- Cost report design.
- Cost reporting tools development for state specific criteria.
- Cost report collection, database management, and analytics.
- Nursing facility reimbursement:
- Reimbursement system design, development and implementation, including
acuity based systems. - Design, development, and implementation of RUG case mix rate setting systems.
- Medicare Patient-Driven Payment Model evaluation and identification of best solutions for implementing and/or modifying case mix reimbursement system.
Check out our updates on what states should be considering as they prepare for PDPM:
PDPM Calculation Using OBRA Assessments - Ancillary cost finding – apportioning ancillaries between payors.
- Annual/semi-annual/quarterly rate calculations.
- Nursing facility rate setting rebase/updates.
- Add-on rate development for specific services.
- Fair rental value consulting.
- MDS rate setting rosters and case mix index (CMI) reporting/calculation.
- Post MDS verification review rate revisions.
- Cost settlement calculations and notice of program reimbursement.
- Reimbursement system design, development and implementation, including
- Quality incentive programs:
- Value-based purchasing (VBP)/pay-for-performance (P4P) program development,
administration, and oversight. - VBP auditing.
- Quality measure reporting, consulting, and clinical training.
- Value-based purchasing (VBP)/pay-for-performance (P4P) program development,
- Minimum data set (MDS):
- MDS secure web portal delivery system.
- MDS management and analytics.
- MDS help desk.
- MDS verification reviews (CMI oversight).
- Post MDS verification review re-rugging.
- Web-based submission and communication system design (web-based portal) for cost
report, MDS roster distribution, payor source changes, and supporting documentation. - Hospital back-up clinical assessments.
Legislation and Regulation
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 Amy Perry, CPA |
We have supported our clients through significant periods of change since the inception of the Medicare and Medicaid programs. Our national experience in reimbursement system design for nursing facilities is comprehensive from inception of concept all the way through implementation and on-going maintenance. Our services include:
- Regulation and policy development support.
- Federal medical authorities consulting.
- State plan amendment.
- 1915(c)/(b), 1115, and 1132 waivers.
- Administrative code consulting.
- Public hearing and workgroup participation.
- Expert testimony.
- Analysis of programmatic and fiscal impact of proposed or passed legislation.
Benefit/Program Integrity
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 Ryan Farrell, CFE |
Through our benefit/program integrity services, Myers and Stauffer is able to assist our government health care clients in performing reviews of nursing facility claims to ensure provider payments are made in accordance with applicable state regulations and policies. Our services focus on the following areas: accuracy of per-diem and patient liability, adequacy of documentation, verification that the required prior authorization has been obtained, and proper application of leave of absence days and date of death or date of discharge policies. Additionally, we perform credit balance reviews to assist with recovery of provider overpayments. Our program integrity services include:
- Claims analysis.
- Post-pay claims audits – clinical and financial.
- Pre-pay claims audits – clinical and financial.
- Medicaid recovery audit contractor (RAC) services.
- Software modules for surveillance and utilization review subsystem (SURS), fraud
and abuse detection services (FADS), and case tracking. - Provider compliance.
- Payment system processing accuracy.
- Fraud, waste, and abuse detection (FWAD) litigation support.
Litigation Support
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 Missy Parks, CFE, AHFI |
Myers and Stauffer routinely serves as consultants for state Medicaid agency attorneys and state attorney general offices. Services to state Medicaid programs include preparing expert reports/depositions, participating as expert witnesses, and assisting with cross-examination of opposing expert witnesses. These cases may involve defending the state against lawsuits or supporting the state in legal actions against various patient-care providers and managed care entities. Services include:
- Appeals/litigation support (testimony and administrative support).
Medicaid Financing and Reporting
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Amy Perry, CPA |
Our team, which include former CMS analysts, possess many years of experience and a variety of skillsets that have been applied in several states to address federal reporting needs. We have helped states resolve issues effecting outstanding grant award finalizations as well as identify unclaimed federal funds prior to filing deadlines. Our ultimate goal is to provide our clients with the training, knowledge, tools, and skills necessary for state agency staff to fully manage the federal reporting process. Services include:
- Certified public expenditures (CPE) claims – reconcile claims to cost report data.
- Calculate fiscal impact estimates.
- Analyze upper payment limit (UPL) methodologies.
- Demonstrate federal UPL compliance, including calculations and narrative.
- Supplemental payment program design, calculations, and oversight.
- Provider tax program development and compliance.
- Provider tax calculations.
- Program financing consulting.
Stakeholder Engagement
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John Dresslar, CPA |
We recognize that in order for a Medicaid program to be successful, productive relationships should exist between the agency and the provider industry. We work alongside our clients to build a professional and productive relationship with stakeholders to ensure efficient and effective program management. Our services include:
- Provider training.
- Work group participation.
- Stakeholder facilitation and outreach.
Managed Care Oversight and Compliance
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 Mike Johnson, CPA, CFE |
The extensive services offered by our highly skilled managed care engagement team are generally focused on the oversight of health plans (see Managed Care Services) but can impact all provider types, including nursing facilities. These services include:
- Encounter data reconciliation and validation.
- Financial audits, performance audits, and program effectiveness audits.
- Network adequacy assessments and member access compliance.
- Readiness reviews.
- Claims payment and denial assessments, accuracy, and timeliness.
- Medical record review.
- Grievance and appeals analysis.
- Contract compliance.
- Other provider-specific issue review and resolution activities.
