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Nursing Administration

Federal and State governments are engaged in an effort to reduce Medicare and Medicaid fraud and abuse. This effort has created the necessity for facilities to be especially careful that their documentation is complete and accurate. A complete picture of the resident (the condition, functional abilities, and the nursing care required) must be fully presented. H.C.R.S.'s function is to assess the resident population and it's needs, audit the existing documentation, and assist nursing management to attain quality documentation that reflects the level of nursing care given, so that all requirements are met to support the maximum Level of Care, i.e. TILE level.

 
Resident Evaluation

Resident Assessment - We do a 'hands on' evaluation of each Medicaid resident with the direct care staff: CNA, charge nurse, and DON or ADON (if possible). This review of all residents is the first and best opportunity to show the nursing staff how TILE really works and what questions they need to be asking to be sure maximum TILE rate is achieved. Often, unfortunately, it is the first time the 'charting' nurses really talk to the care givers, therefore their documentation doesn't match the real picture of the resident.

Chart Audit - Done in conjunction with the resident assessment, the chart audit often reveals information that can increase the TILE rate. The evaluation and documentation systems we offer can help insure that all required information is captured quickly and accurately so that subsequent reviews and audits sustain the TILE submitted.

 
Pre-TILE Review

Operation Restore Trust and new TDHS/HHSC Practices and Procedures make it mandatory that all facilities have level of care error rates below 20% on their reviews. When notification of a TILE Review is received by a client, HCRS immediately audits those targeted for review, verifies documentation is in place to support the TILE on record, and stays with the client facility through exit and appeal process (if required).

 
Follow Up

60 Day - After our initial visit, a 60-day follow up is usually recommended to assure ongoing accuracy of forms. Because TILE qualifiers are so complex, experience has taught us that it takes a few return visits to thoroughly train the TILE nurse so that she gains confidence and competence. However, some facilities prefer to keep up reviews as long as we find necessary corrections.

Our 60 day review is done following the same procedures, rules, and guidelines that HHSC would use. By this type review, nursing learns exactly what to expect, who they can expect to be reviewed, and yet make any corrections necessary. This also helps avoid Corrective Action.

Semi-Annual Review - Thereafter, a semi-annual Nursing review is recommended to maintain maximum Medicaid revenue. Twice a year each resident may have a change of condition form (Purpose Code R) submitted to change their TILE level if appropriate. These 'off cycle' forms allow the facility to capture higher TILE rates for increased care required by the resident. Thus, as the deadline for these semi-annual periods approach, each resident should be re-evaluated to be sure the TILE rate remains maximized. (Of course significant changes of condition should have this form submitted immediately.)

In some cases, client facilities find it easier and more cost effective to have HCRS complete all TILE forms for them. This insures them that all TILEs are maximized, follow through to payment system is complete, and that all forms are completed on time (thus having no 'gaps' in payment). 

Clients are encouraged to contact HCRS any time they have a question or problem! We are always available via 800 pager, mobil phone, fax, or e-mail.

 
Tracking Tools

Since the conversion to the CMS payment system and the demise of the PSR (Patient Status Report - previously supplied by the state), many facilities have found it difficult to keep track of 3652 Care form due dates, what Purpose Code to do next, and were the forms submitted accepted by the CMS payment system.

HCRS has the tools to track these requirements as well as supplying Administration with an up to the minute average daily Medicaid bed rate. For more information go to our RESOURCES or CONTACT US pages.

 
Training

HCRS believes that all nursing staff should be thoroughly trained in the goals, requirements, and procedures to obtain and maintain correct TILE. This part of nursing's responsibility is frequently the least understood and least practiced, yet it is perhaps the most critical for the financial health of the facility. Our interactive training provides unique methods, insights, and forms to facilitate and motivate each member of the nursing staff to successfully complete these requirements.

The ultimate goal is to get the maximum dollars for the care given. But, like most things, this can not be accomplished by nursing alone. Medicaid reimbursement is a team effort! Nursing, Bookkeeping, and Admissions must each complete their parts completely, accurately, and in the right time frames. Understanding the 'big picture' and how each departments' part fits together works to maximize revenue and give each team member pride in a job well done.

Training is offered as a facility in-service, as a seminar/workshop for multiple facilities, and as a one-on-one as would be in the case for training a TILE Nurse Assessor.

 
Assistance with Corrective Actions and Appeals

Should the need arise, HCRS offers the most qualified help in Texas to master the TILE requirements and achieve satisfactory completion of 3652 CARE forms in order to be released from Corrective Action by HHSC.

In a dispute with HHSC of a TILE change, we can evaluate your documentation vs. TILE claim and assist in presenting your case in both the informal and formal appeal process.

Following all work done by H.C.R.S., we conduct an exit conference followed by a written report itemizing our findings and recommendations.  

 

  

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