The Clinical Reimbursement Integrity Study (CRIS)

A focused effort by Signature HealthCARE to evaluate the quality of the program(s) and methods involved in recognizing the needs of our residents, ensuring that the services provided meet the needs of our residents and that we properly document and secure the appropriate reimbursement earned for the services provided.

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The Clinical Reimbursement Integrity Study (CRIS)

Phase One (Next 90 Days)

  1.  Identify facilities with the greatest opportunities for improvement  (DataPoints, variability from standards, trends, etc.).
  2.  Assign a clinical reimbursement (CR) consultant to work with each selected facility – in conjunction with Rehab Dir. Of Clinical Services – to:
  • assist with the current CR routines
  • learn from the field experience
  • elevate the competencies of the field stakeholders
  • evaluate the current CR environment to understand strengths and weaknesses in processes, training and program design

Phase Two

Develop and implement a specific CR Performance Improvement Plan.

Who – contacts for segment & field stakeholders:

  • Operational Oversight – George Burkley
  • CR Program Oversight – Cleo Boulter
  • MDS Technical Leader – Christa Masden
  • Rehab Technical Leader – Marcie Beaty
  • MDS Technical Team / Consultants – to be assigned by facility
  • Rehab Technical Team – Christine Busby
  • Rehab Consultants – DOCs
  • Financial Leader – Vinnie Barry

What – Phase One Protocol:

Twice Weekly

1.   CR Consultant direct interaction w/each facility MDSC (via phone)

  • RUG / ADL / ADR cycle / COT look back date / Therapy schedule / COT or EOT OMRA required?
  • IHN MDS Scheduler
  • Workflow issues
  • Education (CR orientation completed / CR credential earned)
  • KY Medicaid preliminary reports (if applicable)
  • Certifications & re-certifications and correct documentation trail (medical necessity / minutes match)

2.   DOCs direct interaction with each facility RSM (via phone or onsite)

  • Threshold & efficiency
  • IHN Rehab Forecaster review
  • Workflow issues
  • Education
  • KY Medicaid Part B preliminary reports (if applicable)
  • Certifications & re-certifications and correct documentation trail (medical necessity / minutes match)

Every Two Weeks

  • CR Educational Webinar
  • Status report provided to SHC leadership team highlighting key metrics
  • Conference Calls w/ field leaders for feedback (not mandatory)

Monthly

1.   CRIS project team assessment of CRIS effectiveness

  • Opportunities for improvement

2.   Catalog findings and research related to Phase Two

  • CR staffing model
  • Correlate quality measures with CR measures for robust integrity checks
  • Process improvement
  • Refined DataPoint metrics
  • Research industry best practices and adopt where applicable

When – Phase One Launch:

1.   Interaction between CR mentors, DOCs and field stakeholders begins week of September 12.
2.   Additional interaction occurs as scheduled within protocol outlined previously.