One of the most frequent issues in facilities struggling with Medicare and Medicaid compliance and billing goes back to the basics: running an efficient utilization review meeting. These meetings should be held weekly, establishing open lines of communication between therapy, business office, and MDS and nursing. Who should attend these meetings? Directors of nursing, MDSCs, business office managers, therapy directors, social services (for discharge planning purposes) and administrators. While it is costly to get these leaders into one room for an hour long meeting, missing this crucial meeting will lead to decreased revenue because of lost communication, misunderstanding over discharge planning details, unaddressed ADL coding and lost revenue from unaccounted for secondary payor sources after day 20, to name a few. How much could this cost you? A missed COT could cost the entire 14-30 day with managed care. At a rate of $500/day, at 30 days that is $15,000! Therapy and MDSC usually keep up with these COT adjustments, but formal communication will eliminate any miscommunications.
A missed discharge home date? A patient who converts to private pay with no resources because we didn’t plan discharges well can cost you the daily private pay rate X the number of days until they leave the building. Many of us struggle to collect that unexpected bill from the patient or their family, and mandatory discharge notices require up to 30 days before someone must leave!
Unaddressed ADL coding? A RUG score that is not reviewed by nursing, resulting in a endsplit of an “A” (the lowest ADL score) when they should be have been a “C” (a higher ADL score) can cost the facility $100/day, depending on the facility’s designated Medicare rate.
So what do we talk about in a utilization review meeting? The team runs through each patient, primary and secondary payor source data, therapy progress in each discipline, anticipated discharge dates from therapy and from the nursing facility, discharge plans and nursing issues (medications, respiratory issues, etc.). Often this is a good time to review managed care insurance requirements and their frequent re-approval needs. Remember, this is not a therapy only meeting. Nursing needs to be prepared to discuss their challenges and progress with the resident, focusing on medication changes, pain control issues, hospitalizations, vital sign data, infections, and so forth. A “U/R note” should be added to the progress note section of the patient’s chart, summarizing the information discussed in the meeting. Often, this documentation has saved our $$$ when charts were reviewed by insurance companies and Medicare on audits. These are great weekly summary notes. The investment of a laptop or two in the meeting room often allow the team to type these notes in real time, saving on efficiency of your staff’s precious, very busy time.