Prospective Payment for Long-Term Care 2000-2001:9780834217997:Baker, Judith J.:eCampus.com

Resource Group, Ltd., Dallas, TX. Annual text of step-by-step procedures, concepts, advice, and tools. For long-term care administrators and staff. Coverage includes: how the system works, new case-mix adjusted rate, how SNFs will be affected, how to develop the new information systems needed, and more. Softcover.

Contributors

Foreword

Preface

xiii

Acknowledgments

PART I--- OVERVIEW AND UPDATED PPS RATE CALCULATIONS

(62)

PPS at a Glance

(4)

Introduction

(1)

Implementation Timeline

(1)

Interim Rates

(1)

Base Year

(1)

Items Encompassed by the Rates

(1)

Federal Rate

(1)

Facility-Specific Rate

(1)

RUG-Type Case Mix

(1)

Effect of Changes in Year 2

(3)

Rate Setting Methods

(6)

Introduction

(1)

Federal Rate Methodology

(1)

Facility-Specific Methodology

(1)

The Market Basket Index

(1)

Area Wage Adjustments

(1)

The Association between SNF Staffing Minutes, the Prospective Payment Case-Mix Index, and Price

(3)

Crosswalk of Codes and Groups

(2)

Calculating PPS Interim Rates in Year 2

(20)

Two Rates: Separate Updated Calculations

(1)

The Case-Mix Adjusted Federal Rate

(1)

The Facility-Specific Rate

(5)

Example of Actual Facility Rate Calculations

(2)

Comparison of Three Facilities' Rate Calculations

(2)

Total Payment Affected by Rates and by Patient Mix

(1)

Bookmarks

(3)

Appendix 3-A Wage Index for Urban Areas

(5)

Appendix 3-B Wage Index for Rural Areas

(2)

PPS, the Balanced Budget Act of 1997, and the Balanced Budget Refinement Act of 1999

(30)

Introduction

(1)

Provisions of the BBA: A Health Care Financing Administration Summary

(4)

The BBRA: An Update

(1)

Bookmarks

(1)

Appendix 4-A The Balanced Budget Act of 1997

(21)

Appendix 4-B Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999

(4)

PART II--- HOW DOES THE CASE-MIX PROSPECTIVE PAYMENT SYSTEM WORK?

(38)

PPS and the RUG-III Classification System

(8)

How Does This System Pay? An Overview

(1)

RUG-III Hierarchy of Categories and Groups

(4)

Three-Way Crosswalk of MDS 2.0 RUG-III Codes and M3PI Revenue Codes

(4)

The Resident Assessment Instrument: Source of Patient Classification

(22)

Overview of the Resident Assessment Instrument

(2)

Seven MDS 2.0 Forms

(16)

Relationship to the RUG-III Classification System

(1)

Bookmarks

(1)

Appendix 6-A Resident Assessment Protocol Trigger Legend for Revised RAPs (for MDS Version 2.0)

(2)

Appendix 6-B Example of Utilization Guidelines

(1)

RUG-III as a Patient Classification System

(6)

Janet I. Feldman

Introduction

(1)

Background

(1)

Purposes of a PCS

(1)

Components of a PCS

(1)

Desirable Characteristics and Problems of PCSs

(2)

RUG-III Methods

(2)

PART III--- OPERATIONS AND PPS

101

(32)

First-Year Experience: Similarities and Differences

103

(20)

Elizabeth S. Cornelius

Introduction

103

(1)

The Medicare SNF Part ``A'' Cost-Based System

104

(1)

Resource Indicatiors for Nursing and Rehabilitation

105

(11)

Nursing Dollars Work

116

(1)

Rehab Dollars Work

116

(3)

Summary

119

(3)

Appendix 8-A Definitions of Terms

122

(1)

Under the RUG System for Operations

123

(10)

Cleo S. Boulter

Judith J. Baker

Introduction

123

(1)

RUG-III and PPS

123

(1)

Medicare and RUG-III

124

(1)

Clinical Groups Not Covered Automatically by Medicare

124

(2)

Example: Mr. Smith Classifies to a Rehabilitation RUG-III Group

126

(3)

Medicare Part A SNF Eligibility Criteria

129

(1)

MDS/RUG Relationship

129

(1)

The Assessment Schedule for PPS

129

(3)

Challenges and Opportunities Accompany Change

132

(1)

PART IV--- CASE-MIX STAFFING AND PATIENT CASE STUDIES

133

(36)

New Case-Mix Staffing Simulations

135

(14)

Janet I. Feldman

Introduction

135

(1)

Staffing Simulation: The Family Nursing Home Medicare Unit

136

(6)

Staffing Simulation: The Far-Away Nursing Home Medicare Unit

142

(2)

Staffing Models Based on the RUG-III Classification System

144

(3)

Conclusion: What Is the Point?

147

(1)

Bookmarks

148

(1)

Case-Mix Patient Classification for Payment: Two Case Studies

149

(20)

Janet I. Feldman

Introduction

149

(1)

Case Study 1: Mr. Sam Seez Carson, RUG-III = SSC

149

(9)

Case Study 2: Ms. Reala Multa Better, RUG-III = RMB

158

(9)

Conclusion

167

(2)

PART V--- BILLING, THE GROUPER, AND COST REPORTS

169

(64)

Billing under the Assessment System

171

(10)

Types of Assessments

171

(1)

Available Assessment Windows

172

(1)

Assessment and Billing Schedule Example

172

(3)

Day One Is Day of Admission

175

(1)

Management Tracking, Red Flags, and Penalties

175

(1)

Bookmarks

175

(6)

Computerized Classifications: The Grouper

181

(4)

What the Grouper Does

181

(1)

Versions

181

(1)

Downloding Availability

182

(1)

RUG-III Items Used by the Grouper

182

(1)

Bookmarks

182

(3)

Billing Strategies

185

(22)

Billing under PPS

185

(1)

Coverage Eligibility and Guidelines

186

(1)

UB-92 HCFA Form 1450: New Requirments

186

(1)

HIPPS Rate Codes

186

(1)

Consolidated Billing

186

(6)

Continued Procedure Changes for Facilities

192

(1)

Potential Trouble Spots

192

(1)

Bookmarks

193

(2)

Appendix 14-A HCFA Form 1450 with Instructions

195

(2)

Appendix 14-B HCFA Form 1500 with Instructions

197

(2)

Appendix 14-C Program Memorandum

199

(8)

Cost Report for SNF PPS

207

(26)

Introduction

207

(1)

Cost Reports for Freestanding SNFs

207

(1)

Cost Reports for Hospital-Based SNFs

208

(9)

Bookmarks

217

(2)

Appendix 15-A Selected form HCFA-2540-96 Instructions

219

(5)

Appendix 15-B Selected form HCFA-2552-96 Instructions

224

(9)

PART VI--- PPS IMPLEMENTATION AND TRAINING

233

(34)

Planning for Information Systems

235

(14)

Reasons To Plan

235

(1)

Information Elements and Mandatory Automated Support Status Checklist

235

(1)

Information Systems Planning Steps Checklist

235

(1)

HCFA's Expectations for Automation of the Minimum Data Set (MDS) 2.0

235

(12)

Information Systems Support Tips

247

(1)

Bookmarks

247

(2)

Implementing PPS during Transition

249

(6)

Philosophical Adjustments

249

(1)

Implementation Issues

249

(1)

Operational Emphasis

250

(1)

Operational Changes

251

(1)

Conclusion

252

(1)

Bookmarks

252

(3)

SWOT Analysis for PPS Implementation

255

(8)

Introduction

255

(1)

SWOT Analysis Worksheets

255

(7)

Conclusion: Analytical Planning Benefits

262

(1)

Bookmarks

262

(1)

PPS Training

263

(4)

The Importance of Training

263

(1)

Overview Session

263

(1)

Minimum Data Set (MDS) Assessments, Scheduling, and PPS Session

263

(1)

Nursing Rehabilitation and PPS Session

264

(1)

Rehabilitation Therapy and PPS Session

264

(1)

Administration, Billing, and PPS Session

264

(1)

Computer Operations (Information Systems) and PPS Session

264

(1)

Other Suggestions

265

(1)

Bookmarks

265

(2)

PART VII--- MANAGEMENT DECISION MAKING AND PPS

267

(36)

Financial Analysis PPS in Transition

269

(14)

Analyzing Medicare PPS Rate Sheets

269

(5)

Analyzing PPS Revenue with the Cost Report

274

(3)

Incentives for Cost Management

277

(1)

Costing Methods

277

(1)

Building Case-Mix Cost Spreadsheets for PPS

278

(1)

A Financial Analysis Problem: Tranquility Nursing Home's Case-Mix Spreadsheet

279

(1)

Contribution Margins

280

(1)

Activity-Based Management and PPS

281

(1)

Bookmarks

281

(2)

Tracking Case Mix and Therapy for PPS

283

(12)

Introduction

283

(1)

Tracking Resident Case Mix

283

(1)

Tracking Rehab Therapy

284

(2)

Rehabilitation Therapy Tips

286

(1)

Forecasting for Years 1 and 2

286

(5)

Bookmarks

291

(1)

Appendix 21-A Facility-Wide Assessment Tracking Log

292

(1)

Appendix 21-B Rehab Therapy Maangement Log

293

(2)

Quality Indicators and PPS

295

(8)

Quality Indicatiors as a Component of PPS

295

(1)

Source of QI Data

295

(1)

The Care Domains

295

(1)

Characteristics and Scoring

296

(1)

Regulatiory Uses of QIs: Facility Report Examples

296

(4)

Conclusion

300

(3)

PART VIII--- MEDICAID AND PPS

303

(20)

Impact of the Medicare Prospective Payment System on Ohio's RUG-III Medicaid Case-Mix System

305

(6)

Sheila Lambowitz

Introduction

305

(1)

Adapting the System

305

(3)

Phase I Results

308

(2)

What's Next?

310

(1)

A Fresh Look at the Arizona ALTCS Program

311

(12)

Frankie Gilliam Harrison

Kris A. Kuhlemeier

Introduction

311

(1)

Arizona Health Care Cost Containment System

312

(1)

Arizona Long-Term Care System

312

(2)

Study Methods

314

(1)

Study Results

314

(6)

Challenges for the Future

320

(1)

Conclusions

321

(2)

PART IX--- CONCLUSION

323

(10)

What's Next

325

(6)

Robert E. Burke

Introduction

325

(1)

PPS Objectives

325

(1)

Differences between SNF PPS and the Demonstration

326

(1)

Responses to the Reality of the PPS and the BBA

326

(5)

Today's Actions and Reactions

331

(2)

Did the Sky Fall?

331

(1)

Philosophical Adjustments

331

(1)

Next on the Horizon

332

(1)

Positive Reactions

332

(1)

PART X--- MEDICAID AND PPS

333

(148)

Appendix A--- Glossary

335

(2)

Appendix B--- Resources

337

(2)

Appendix C--- Metropolitan Statistical Areas

339

(10)

Appendix D--- Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Interim Final Rule with Comment Period

349

(68)

Appendix E--- Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities---Update; Final Rule and Notice

417

(60)

Appendix F--- Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities---Update; Correction

477

(4)

Index

481

(6)

About the Author

487

(2)

About the Contributors

489


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