Case Mix Strategies to Optimize Your Medicaid Revenue

Case Mix reimbursement operates on a weighted scale, the more resources needed to provide resident care, results in a higher CMI score and a higher reimbursement level. The Minimum Data Set (MDS) Assessment is used by states to collect objective data regarding a resident within specific timeframes, across multiple disciplines. When an MDS assessment is completed, a clinical score that reflects resident acuity is assigned. This clinical score, known as a Resource Utilization Group (RUG) level, correlates with direct care costs in a Case Mix reimbursement system.

Implementing systems that strengthen documentation of care provided and data capture in the MDS assessment, can have a significant impact on a provider’s Medicaid revenue.


Develop a “Case Mix State of Mind”

Successful implementation of processes that support a Case Mix mindset require application year-round. With continual use of selected methods, the Interdisciplinary team (IDT) members never fall out of practice.

Developing a Case Mix State of Mind means focusing attention on resident care, bringing services that directly impact a provider’s CMI to the forefront. Direct care nurses are firsthand evaluators of clinical changes in residents. Each time a clinician meets or treats a resident, a head-to-toe scan is performed. This information can be translated into criteria for CMI capture. For reimbursement nurses, learning to look beyond OBRA cycles allows them to concentrate on resident care and changes in condition. As acuity changes occur, they can be captured, which positively impacts Medicaid reimbursement.


Best Practices for MDS Coordinators

When MDS Coordinators integrate strategies that strengthen their CMI capture process, it often results in the most accurate and optimized Medicaid revenue. Many MDS Coordinators succeed by establishing processes for before and after an assessment is completed.

Prior to assessment completion, systems that encourage MDS Coordinators to monitor residents for clinical changes are valuable. Consider increasing communication with clinicians regarding resident rounds and encouraging strong documentation for long-term residents. To ensure assessments are completed timely, MDS Coordinators can schedule their MDS cycle earlier than 92 days. After submission, MDS Coordinators frequently use a tracking system to verify all assessments were submitted and accepted, review every MDS Validation report and routinely review Casper Missing Assessment reports.

Routine Assessment and Analysis

External review of Medicaid reimbursement can help to objectively identify opportunities to improve Case Mix Index processes and optimize Medicaid revenue.

Celtic Consulting educates and assists providers with identifying the basis of revenue decline and helps facility teams implement systems to correct and monitor changes over time. Subject matter experts provide in-depth analysis of resident records to determine MDS Coding inconsistencies and case mix system inefficiencies hindering reimbursement. Celtic’s best practices have helped providers in multiple states improve accuracy and reimbursement as a result. The firm offers services that support clients in identifying opportunities to optimize their case mix system processes.


Consider an MDS Completion Service

Providers rely on the MDS Coordinator position to recognize criteria for RUG levels and capture the most accurate CMI for resident care. For most, their MDS Coordinator holds the key to optimize CMI rates and Medicaid revenue.

Some providers opt to supplement or outsource their MDS department to MDS completion services, recognizing the high-level qualified staff those services offer. MDSRescue provides remote interim MDS completion services for facilities nationwide. Subject matter experts ensure assessment completion conforms to regulations, is accurate and timely, and capture data to optimize CMI rates.

Maureen McCarthy is nationally recognized as a luminary amongst long-term care operators and clinicians for Reimbursement and Regulatory matters, Audits, Enhancing Operational Efficiency, Education and Litigation Support. Maureen combines clinical expertise with regulatory acuity, to assist clients with developing sustainable remediation plans. She is a registered nurse with over two decades of work experience, including direct patient care, MDS Coordinator, Director of Nursing, Rehab Director, and Medicare biller.

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