The Benefits of Connecting with a Clinical Reimbursement Consultant

The goal: Leave no money on the clinical reimbursement table. The way to do that: Determine how to leverage MDS while striving for improved accuracy.

As the key driver for Medicare payment and many state Medicaid reimbursement systems, MDS is especially critical for long-term care providers. Even a minor adjustment in your Medicaid case-mix score can mean a significant increase in revenue—money that you are entitled to receive. 

The implementation of PDPM makes accuracy in reporting even more critical to your financial bottom line. But this process is complex, complicated, and time-consuming, as Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, CIC, QCP, IPCO, Director of Clinical Reimbursement for LeaderStat explains. “The MDS RAI User’s manual is 1309 pages long, with six distinct chapters and many appendixes and glossaries. The Patient-Driven Payment Model (PDPM) is still fairly new to Medicare reimbursement, and state Medicaid Case Mix methodologies can vary from state to state.”

The solution to this dilemma? An MDS consultant who can assist your team and the MDS coordinator in navigating the increasing complexities of clinical reimbursement.

So, how does an MDS consultant help facilities get the revenue they are entitled to receive?

At LeaderStat, our consultants work with a facility’s personnel, including the MDS coordinator, to assess the organization’s performance and identify opportunities to enhance both financial and clinical outcomes by— 

• Ensuring accurate MDS assessments. 
• Making sure reimbursement rates correctly reflect patient acuity levels. 
• Evaluating ADL and section GG scoring accuracy. 
• Enabling backup documentation to support your HIPPS and RUG scores. 

LeaderStat’s consultants also provide the training, tools, and support that allow healthcare organizations to put clinical reimbursement worries to rest. These services include— 

• Offsite and on-site support and training for MDS, Case Mix, and PDPM. 
• Case-mix and reimbursement review. 
• Evaluation of documentation systems to measure compliance. 
• Benchmarking tools and quality measurement analysis. 
• Operational support for IDT process, staffing ratio, and other clinical functions. 
• Assisting in MDS Nurse Coordinator hiring. 

The compilation of these MDS consultation services provides an array of benefits, an umbrella if you will, of strategies and tactics that sustain clinical reimbursement at its highest level, protecting the company’s financial bottom line. These benefits include—

• An understanding of where specific reimbursement opportunities exist.
• A financial forecast via historical reimbursements. 
• Profit protection by lessening potential audit risks.
• Growth and efficiency in sustaining Medicare business.
• Greater ability to monitor and identify at-risk patients and thereby increase patient adherence.

Facilities may not see the need to seek assistance until they notice a decreasing trend in reimbursements or inadequate coding results in quality measures being flagged as an indication of poor care. But there’s no reason to delay contacting a consultant until a situation causes concern, or worse, results in a crisis.

“With the level of complexity and the potential ramifications to facilities if the MDS process is not followed correctly, having a resource for your team to turn to when they have questions or need guidance is critical,” states Heichel. “A consultant can provide the needed education, teaching, training, auditing, and mentoring that will help put your facility in a position to be successful.”

The best-case scenario for consistently receiving the revenue that you are entitled to receive? Establish an on-going partnership with a consultant who can, over the long-term, provide consistent, knowledgeable assistance in navigating the complexities of MDS and PDPM.