Nursing Facility Case Mix and MDS Verification

Myers and Stauffer is at the forefront of developing and implementing case mix reimbursement approaches. Our Medicaid nursing facility case mix reimbursement experience is the most extensive in the nation. We have developed, implemented and evaluated acuity-based reimbursement systems that match payment to care needs, provide incentives for access and quality of care, utilize existing infrastructure and maintain reimbursement within appropriate funding levels.

Working with our clients, their advisory boards and provider associations, we arrive at an acuity measurement system that operates in a personal computer environment and is responsive to each state’s unique situation. Using resident acuity and cost data, we construct models that provide a numeric snapshot of how the current system operates and, by changing various program parameters, show how reimbursement changes within different options. We have found this side-by-side analysis is an effective means of determining how payment rates will be affected and estimating the impact on the budget and provider community.

Our services include: linking MDS data to the Medicaid agency for case mix rate setting; calculating acuity levels; developing case mix indices; developing the reimbursement formula; computerizing the rate setting formula; modeling and analyzing the system; providing recommendations to the state following modeling; and implementing, evaluating and maintaining on-going operations of the new system.

Once a case mix, RUG-III-related, reimbursement system is implemented, the next step is to develop a validation process to review MDS elements directly related to the RUG-III calculation. The validation process assists in protecting states’ fiscal interests by ensuring integrity in the data that drives payments. Myers and Stauffer has assisted several states with developing a validation process designed to meet the specific goals of each state. As a result, states have experienced a higher rate of MDS accuracy, which contributes to the overall usefulness of the MDS for care planning, reimbursement, quality indicators, quality measures, quality control and state policy-planning efforts.