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PPS, MDS, Do It For Less: Or Are We Blessed?


Clint Maun, CSP

The title of this article reflects viewpoints and attitudes related to dramatic changes that are occurring in the Medicare reimbursement system. It's important to understand these changes will have long-term effects and will affect design reimbursement methodologies for state Medicaid programs and eventually many other payment systems.

The Prospective Payment System


Many of our clients are focusing on the middle word, which is involved with payment knowledge. It's important to understand the payment mechanism and how the "RUGs" classification system will affect reimbursement. It is also important to understand how critical documentation and team based involvement is in capturing data.

Some of our clients are focusing on developing the "system" word at the end of the PPS acronym. The systems include software programs, documentation, and formats, the MDS, tie in to reimbursement, etc. It is critical that the system approached be developed so there is an immediate knowledge base that can be utilized for decision making and capturing of information for reimbursement purposes.

While we don't want to portray these two areas mentioned above of "payment" and "system" as non-critical, it is also important to point out that the most important word in the new reimbursement system is the first word. That word is "Prospective". Simply put it means we're looking forward, not waiting for a retroactive approach to delivering services or receiving reimbursement. The perspective on prospective is that it will turn out to create an important mind-set change for many organizations. We believe this is a positive step in reimbursement and organizational success for the future. It would be nice to believe that over time, after the wrinkles are smoothed out in a reimbursement system, you could have a clear cut understanding of what you're dealing with before accepting an involvement with a customer.

We believe that PPS will be a "God-send" to the industry because it allows us to focus on an approach that is designed to utilize our critical thinking skills. Much the same as Minnesota Fats was a more successful pool player than most; he would admit that many people could hit the cue ball into the 9 ball and knock it into the pocket. Minnesota Fats too could hit the cue ball into the 9 ball and knock it into the pocket. The difference was that before the shot, he knew where the cue ball was going. In other words, he set up his shots so he didn't get blocked in, and then ran the entire table for success against his competition. This is also true of successful baseball pitchers who set up pitches on various parts of the strike zone to eventually strike out the batter. A good tennis player sets up two or three shots for a future winning shot.

Critical thinking skills have been hampered by a retroactive reimbursement approach. We've not been able to think through decision making concerning who we take, what we do with them and how we become successful for them and us. Instead, we've been concentrating on hoping to do it, bill it and pray the money comes in our direction. With a perspective on prospective, it is now possible to focus our entire team on this effort about issues such as:
  1. What types of customers we should be involved with?
  2. What should our market niche be?
  3. Understanding there is a true mix of quality and quantity of care before we take an involvement with a new customer.
  4. Realizing a general sense of team play be developed to achieve the appropriate documentation for reimbursement.
  5. Encouraging a method of critical thinking that begins with assessments that are done at the beginning of involvement with a new customer and continues through the care planning process, through the successful implementation of our effort with that particular customer.

The Perspective Payment System therefore allows us to set up a process where we can control how we get involved in the game, set up the shots and become winners along with our customers.

If you'd like more information on how to be a leader for change in your organization, click here.

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