Medicare Review Meeting

Medicare Review Meeting

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Policy:

Representatives from the Interdisciplinary Team (IDT) will meet at least weekly to review all residents utilizing benefits under Medicare Part A, Medicare Advantage, or Medicare Part B.

Goal:

To maintain the provision of quality, resident-focused care, prevent fragmentation of care through effective communication among the IDT, ensure compliance with Medicare regulations, and ensure appropriate utilization of resources and accuracy of billing and reimbursement.

Procedure:

I. Meeting Participants:

Members of the IDT who should be present at the Medicare Review Meeting include:

• Resident Care Coordinator (RCC)
• Nursing Management Designee (e.g., DNS, ADNS, Supervisor, or Charge Nurse)
• Director of Admissions
• Rehab Program Manager
• Social Worker
• Director of Finance
• Administrator (highly recommended)

II. Meeting Agenda:

The IDT will review the following areas:

A. Resident Review:

• Current treatment plan
• Clinical, functional, and psychosocial status
• Educational needs
• Projected discharge date and status of the discharge plan
• Changes in condition and resulting new needs
• Reimbursement requirements, consolidated billing issues, and customer satisfaction issues

B. Medicare Technical Aspects:

• Patient-Driven Payment Model (PDPM) scores
• Assessment Reference Dates (ARD)
• PPS schedule and MDS due dates
• Medicare days used
• Last covered day
• Certification/recertification dates
• OMRA dates
• Dates to issue timely denial notices

C. Completion of Medicare Review Form:

• Document pertinent resident information: admission dates, PDPM scores, skilled services, last covered day, projected and actual discharge dates.
• Update the form at each meeting and ensure it is signed by all attendees.
• The RCC Coordinator is responsible for accurate completion of the form.
• Maintain the Medicare Review Form per medical record policy.

III. Roles and Responsibilities:

A. Resident Care Coordinator:

• Facilitate the Medicare Review Meeting.
• Ensure the format is followed and discussion remains focused.
• Initiate discussion on each resident, reporting key details (name, diagnosis, estimated/current length of stay, projected discharge date, last covered day).
• Remain knowledgeable about each case, including pre-morbid history, medical, clinical, functional, and psychosocial status, discharge disposition, and community resources anticipated.
• Keep the IDT informed of each resident’s assessment schedule and coordinate the due dates of additional MDSs required, such as OMRAs.
• Report ARD and anticipated and actual PDPM scores.
• Ensure adjustments to the resident care plan as new problems or needs are identified.
• Ensure teaching goals are reflected in the resident care plan and adjusted based on the resident/family response to education.
• Provide the Director of Finance with RUG Validation reports.
• Assess eligibility for continued coverage under medical categories for residents who have met their rehab goals.
• Notify the IDT when a resident no longer meets the criteria for continued stay based on Medicare guidelines for skilled level of care.
• Track residents for 30 days post-termination of benefits to determine if return to skilled care is appropriate.
• Follow residents for 60 days to end benefit period and notify the Director of Finance of this benefit period end date.

B. Nursing Management Designee:

• Keep the IDT informed of active clinical issues, resident’s progress, and response to treatments.
• Bring resident teaching forms to the meeting and provide an update on the resident/family response to education.
• Act as a liaison between the IDT and the physician on clinical issues and obtain orders for services as needed.
• Ensure skilled nursing services provided to residents are appropriately documented in the medical records.

C. Rehabilitation Program Manager:

• Provide a brief description of the resident’s rehab progress during the reporting period and an overview of the resident’s functional status in areas such as bed mobility, transfers, ambulation, toileting, dressing, and bathing. Report the amount of assistance required for each activity and any cognitive deficits impeding progress.
• Communicate the best dates for ARD based on therapy utilization and coordinate with the RCC Coordinator in setting the final ARD.
• Ensure skilled therapy services provided to residents are appropriately documented in the medical records.

D. Social Worker:

• Provide a brief report on the status of the discharge plan, including anticipated discharge destination, barriers to discharge, actions taken to address the barriers, and community services anticipated at discharge.
• Review the final discharge disposition with the team, including community referrals, transportation arrangements, and timing.
• Consistently communicate any customer complaints reported, the plan of action established to address the complaint, and the resident/family response until the problem is resolved.
• Provide pertinent information related to family psychosocial issues that impact the treatment plan and/or discharge planning.
• Maintain a discharge calendar to be distributed to IDT members and delivered to nursing units.

E. Director of Admissions:

• Provide the IDT with information on new admissions, including the reason for admission, diagnosis, payer, payer requirements, anticipated last covered day, discharge disposition if known, caregiver concerns, or any other pertinent history prior to hospitalization.
• Review anticipated ancillary utilization (services required, DME needs, etc.) of new admissions with the IDT.
• Review census with the IDT, including anticipated admissions, LOAs, and hospitalizations.
• Issue technical denial notices to residents as required.

F. Director of Finance:

• Provide the IDT with residents’ financial information, including Medicare days utilized, last covered day, secondary payer sources, and coinsurance availability.
• Review the status of claims under Probe review and/or appeal process.
• Track and report on benefits exhausted and gap billing for residents who remain in the facility at a skilled level of care.

IV. Meeting Rules:

• Start consistently at the designated time and keep the meeting as short as possible.
• All members of the IDT are expected to come on time and remain until the meeting is completed, avoiding interruptions unless emergencies arise.
• Only one person speaks at a time, and the communication flow should remain focused on the agenda.

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PPDM - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]