Most facilities despite the transition issues, have completed the Medicare Part A billing for October 2010. Using the billed RUG-IV days from several facilities, Harmony has prepared a Hybrid RUG-III (HR-III) analysis using a formula to transfer the RUG-IV days to the Hybrid RUG-III grouper. The HR-III analysis reflects extrapolated days using a very conservative formula. The outcome of the % difference in the Medicare Part A Rate and Medicare Part A Revenue will differ based on each facility and the type of patients treated. For example, if a facility provides in-house IV fluids this could increase the reimbursement under the HR-III grouper. Conversely, facilities that have been providing care to patients who require isolation for active infectious disease will need to budget for a steeper financial pay back.
A key factor is that the majority of SNFs have the highest percentage of Medicare Part A Days in the Rehab categories. The extrapolation of Rehab billed days between RUG-IV and HR-III is very similar based on the fact that Medicare did not change any of the minute requirements. The nursing RUG categories typically comprise a small percentage of the RUG days, which usually falls between 10%-15%. Calculation of the Hybrid RUG-III classifications can be fairly accurately done with Rehab scores. The nursing scores which were reported by the facilities for RUG-IV were very conservatively calculated to HR-III scores. To obtain the most accurate Hybrid RUG-III calculation of monthly revenue, Harmony can provide an on-site review of all MDS assessments and days billed for the month to determine how each score will be targeted, either for a reduction or increase in reimbursement.
Harmony provides further insight into comparison of RUG-IV Revenue vs. Hybrid RUG-III Revenue.
A patient who requires isolation for active infection, coded on the MDS 3.0 under RUG-IV with an ADL score between 2-16 will yield an Extensive Service 1 score (ES1). This same patient would not yield an Extensive RUG score under the Hybrid RUG-III grouper. Under Hybrid RUG-III, the MDS software will look for another clinical qualifier to classify the assessment into a nursing RUG category. If this patient received Respiratory therapy, then the MDS 3.0 would yield a HR-III score of Special Care (SSB).
Sample based on Massachusetts rates for Essex County:
- ES1 (coding Isolation) Rate: $493.71 x 14 days = $6,911.94 (RUG-IV)
- SSB (coding Respiratory Therapy) Rate: $360.57 x 14 days = $5,047.98 (HR-III)
- $ Impact Difference: ($1,863.96) paid back to Medicare
- % Difference: 27%
Harmony is pleased to report that of the analysis completed, the overall % reserve has calculated between 8 - 12%. This has been received with much relief compared to the originally forecast 20% reserve.
