DVA Community Nursing Education Package for March 2017

DVA Community Nursing Education Package for March 2017 Part 3 Claiming and Reporting Information correct as of March 2017 1

Objectives At the end of this session you will have: – A good understanding of DVA’s claiming and reporting requirements and obligations within the Notes – A good understanding of DVA’s preferred method of claiming and how to complete the MDS Collection Tool in line with the Notes Information correct as of March 2017 2

Claiming A CN provider retrospectively claims for the delivery of community nursing services to an entitled person through the Department of Human Services (Medicare) An entitled person must never be asked to provide additional payment for the delivery of community nursing services by a CN provider A claim for payment for community nursing services, must be submitted to Medicare within six months of the first day of the 28 -day claim period Information correct as of March 2017 3

Submitting Claim for Payment In submitting a claim for payment the CN provider certifies that the community nursing services: • were delivered by the CN provider or a subcontractor • were provided under a treatment/care plan for the entitled person • are a true representation of the community nursing services actually provided Information correct as of March 2017 4

Inappropriate claiming for services DVA has systems in place to monitor the servicing and claiming patterns of services provided under the DVA Community Nursing program Inappropriate claiming can incorporate: • Over-servicing • Under-servicing • Fraud DVA will recover any overpayments identified during regular contract management post-payment monitoring processes as part of the QF and take appropriate action under the Agreement Please section 11. 14 of the Notes Information correct as of March 2017 5

Data reporting requirements Providers are required to submit data on all community nursing services delivered to entitled persons in each 28 -day claim period Data is presented in the DVA Minimum Data Set (MDS) format DVA uses MDS data to: • monitor the appropriateness of the provision of community nursing services • substantiate community nursing claims • ensure that an entitled person receives quality health outcomes • assist in research into program development Please see Attachment F of the Notes Information correct as of March 2017 6

Minimum Data Set The MDS collects information on: Claim Details • entitled person’s surname, file number, item number and claim start date Staffing Resources Used (in the 28 -days) • level of personnel delivering community nursing services to the entitled person • visits/occurrences and hours of care provided by each level of personnel delivering community nursing services to the entitled person Information correct as of March 2017 7

Visit vs Occurrence Visit: A visit is where only 1 type of care is delivered. For example, A NSS only providing personal care in a visit Occurrence: An occurrence is defined as the total number of different visit types completed by the RN or EN. Each component of the care delivered should be counted and recorded in the MDS as a separate occurrence There is a possibility in one visit there maybe three separate occurrences of services being delivered, e. g: • core item • opposing schedule add-on • palliative care (other items add-on) Information correct as of March 2017 8

Example of an occurrence for MDS purposes? An RN makes four visits in a 28 -day claim period (one visit per week), each visit lasts 1½ hours. Within each visit, half an hour of personal care services are delivered by the RN and one hour of Clinical Care. A total of eight visits/occurrences will be recorded over the 28 -day claim period, with the MDS being reflected as follows: Information correct as of March 2016 9

Submitting Minimum Data Set How to submit MDS Data: • Online to Department of Human Services Medicare (Medicare) as part of the Medicare claim • MDS data must be submitted at end of each 28 -day claim period • If a CN provider has multiple sites with multiple provider numbers, each site must submit its own MDS data Information correct as of March 2017 10

Same classification, different staff resources used MDS Submission example The entitled person has multiple wounds / ulcers on both legs requiring wound care x 3 per week, each visit taking 45 minutes and requires hygiene assistance x 3 per week and due to cognitive issues and frailty, hygiene assistance takes 45 minutes Provider A - RN provides both the clinical and Personal Care Provider B - NSS provides Personal Care and RN to provides Clinical Care Classification is the same in each case, as is the fee paid, however the MDS will be reflected differently Information correct as of March 2017 11

Same classification different staff resources used MDS Information correct as of March 2017 12

Contacting Department of Human Services Enquiries relating to claiming e. g. rejected claims, can be addressed by contacting the Department of Human Services (Medicare) on 1300 550 017 (option 2) 13