OIG says nursing home reimbursement too vexing

While nursing homes generally follow a systematic process when implementing resident assessments, significant differences exist between the Minimum Data Set (MDS) used for that assessment and the rest of the medical record. Worse yet, the Resource Utilization Groups that flow from the MDS and drive Medicare reimbursement are either upcoded or downcoded 76% of the time, according to reports just released by the Department of Health and Human Services’ Office of Inspector General (OIG).

"It is certainly no surprise to anybody that the MDS is not accurate," asserts health care attorney Marie Infante of Mintz Levin in Washington, DC. "Anybody who has taken the time to look at their own coding and compare it to the medical record can verify that there are as many mistakes as the OIG found."

Infante says the underlying problem is that the MDS is a highly complex instrument that requires some very specific knowledge. But it is often a transient staff that are trying to comply with those requirements, she adds.

"It is going to be a constant source of problems, in part because of training and education and turnover issues, and because the instrument itself is not a model of perfect clarity," she argues. "It requires a level of training and consistency that is not found at most facilities."

According to Infante, the good news is that the OIG’s report to some extent might insulate providers from any charge of intentional wrongdoing. "What the report shows is that nobody knows what they are doing," she contends.

Infante also argues that facilities must establish strong, concurrent audit processes on their billing submissions before they are submitted to make sure they are substantively accurate. That means looking at a relevant sample of the number of claims being submitted and checking to see whether the documentation supports the billing.