Ask the Experts

Ask the expert: HMO resident concerns

Q: I live in Ohio. For a couple of years now we have completed our HMO residents in the following way:

  • We complete an admission assessment only because we are not to submit PPS assessments on HMO residents.
  • If that resident has a Medicaid number we code that in Section A. Subsequently these assessments are counted into our quarterly Medicaid-only case-mix which is RUGS 3 in Ohio

A colleague recently questioned this practice and stated that it seems like “double-dipping” since we are getting paid from the insurance company. Is this practice legal and acceptable and if so are you able to cite where I can find documentation that it is so I can “prove” it to this colleague.

A: Because your question is so specific to the State of Ohio, you need to contact the RAI coordinator for the State of Ohio. What is captured on the MDS is for identification purposes and does not dictate how the State of Ohio chooses to use the information. The instructions in the Manual state to record the numbers if the patient has them. There isn’t any nuanced information for specific situations. In the past the State of Ohio used this information differently than other States in tracking Medicaid patients. If the RAI Coordinator in Ohio can’t provide you with the correct information, then she should be able to provide you with a contact number for someone in the DPH that can help you answer your questions and ensure you are completing the MDS accurately.