AMBR Journal, January 2020

JANUARY 2020 | Vol. 2 No. 1

JOURNAL

A NEW ROAD LIES AHEAD Entering a new age in SNF billing

Association for Medicare Billing and Reimbursement for Long-Term Care

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CONTENTS

FEATURES

DEPARTMENT

5. Consolidated billing made simple

3. Director’s note

Sounding the alarm on consolidated billing rules for ambulance trips

We did it. PDPM has been implemented, and now we can start assessing how it affects skilled nursing facilities.

13. Your interdisciplinary team Opportunities to incorporate restorative nursing into your care plan

15. Measuring success under PDPM Key performance indicators to understand how PDPM is affecting your facility

20. Expert Q&A What will it take for SNFs to succeed in 2020?

JOURNAL

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AMBR Journal | JANUARY 2020

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DIRECTOR’S NOTE We did it. PDPM has been implemented, and now we can start assessing how it affects skilled nursing facilities. It’s not time to be complacent—billers and administrators need to learn how their facilities are performing within the PDPM universe. AMBR is here to help guide you through that assessment.

We also will never stop covering the basics. Consolidated billing should always be a constant learning opportunity.

I’m so pleased to offer you this Journal in hopes it will help your SNF succeed.

A networking and learning opportunity: Post-Acute Care Forum Fit a year’s worth of meetings in at this action-packed networking event. There is no registration cost for qualified delegate attendees. The Forum takes place in Chicago from April 6 to 8, 2020.

Who attends: This event is specifically designed for decision-makers at skilled nursing facilities and home health agencies (Manager, Director, Owners/Operators, or VP), who have projects in the pipeline and are actively sourcing solutions.

What you can expect: ❚ Meet one-on-one with solution providers specific to your current project needs ❚ Attend workshops and sessions ❚ Network with peers from leading companies ❚ Receive complimentary event registration, hotel accommoda-

tions, and meals at a luxury venue How it works: ❚ You select the solution providers you’re most interested in meeting ❚ Your interests shape your agenda of one-on-ones and

sessions ❚ We continue to add workshops up until the event ❚ We cap our attendance at 50 spots ❚ We hold the event twice a year and rotate regionally

JOURNAL JANUARY 2020 | Vol. 2 No. 1

EDITORIAL Product Manager Jaclyn Fitzgerald jfitzgerald@hcpro.com Director, Content Tami Swartz tswartz@hcpro.com Contributor Julie McCoy juliemccoy9@gmail.com Copyeditor Adam Carroll acarroll@hcpro.com

SALES National Sales Manager Amy Roadman aroadman@hcpro.com

DESIGN Creative Designer Karen Christner kchristner@simplifycompliance.com

ADVISORY BOARD Maureen McCarthy, RN, BS RAC-MT, QCP-MT, DNS-MT President/CEO, Celtic Consulting, LLC Torrington, Connecticut Frosini Rubertino, RN, BSN, C-NE, RAC-CT, CDONA/LTC Executive Director, Training in Motion, LLC Bella Vista, Arkansas Reta A. Underwood, ADC President, Consultants for Long Term Care, Inc. La Grange, Kentucky Mary-Jo Wilson Billing Consultant, Project Manager, Marketing Assistant, SNF-Solutions, LLC North Bend, Washington Deborah Collum, MS Director of Billing, Covenant Retirement Communities Skokie, Illinois Stefanie Corbett, DHA Postacute Regulatory Specialist, HCPro Middleton, Massachusetts Meridath Death Independent Consultant Virginia, North Carolina Becky Ziviski, CPA, LNHA CEO, Profit Without Census Swanton, Ohio Jennifer Matoushek, MBA/HCM, CPC Senior Consultant, LW Consulting, Inc. Toledo, Ohio

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Why you should attend as a delegate: ❚ It’s a more efficient way to source solution providers, and to get custom attention specific to your needs ❚ You’ll make profitable connections to help

further your business goals ❚ You’ll stay up-to-date about the latest trends

and technology advances in your industry Forum Events has 20+ years of experience holding successful events across multiple markets. We’re dedicated to providing you with a complete VIP experience from start to finish.

For more information, please contact... ❚ Ryan Vincent—National Account Manager 800-727-5257 ext. 2237 rvincent@blr.com ❚ Adrienne Trivers—Event Manager

781-639-1872 ext. 3207 atrivers@blr.com

PDPM emphasizes the need for the interdisciplinary team to develop an appropriate plan of care for each patient, and there are opportunities to incorporate restorative nursing into your care plan. Expert Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS, senior healthcare specialist with PointRight, Inc. speaks on the subject.

Our next story dives into which key performance indicators to review to determine success under PDPM. Preparation is over and now it’s time to see how the new system affects your facility. This article also guides how to review the Medicare cost report for true assessment.

And finally, we take a hard look into what SNFs will need to succeed in the year 2020 and beyond.

There is truly a wealth of information and practical guidance packed into this issue’s Journal.

We hope you learn, enjoy, and benefit.

Sincerely,

In this issue Consolidating billing will always be a focus, so in this installment of our series that focuses on the topic, we explore the rules surrounding ambulance trips, which are extremely expensive for SNFs and their Medicare Part-A covered patients.

These costs create significant risk. Learn how to determine what is covered and how best to bill.

Read a side bar on education and communication that proves critical to managing ambulance costs.

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Tami Swartz Director, AMBR tswartz@hcpro.com

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CONSOLIDATED BILLING MADE SIMPLE

Sounding the alarm on consolidated billing rules for ambulance trips The Consolidated Billing Made Simple series delves into the ins and outs of consolidated billing. This series untangles CMS consolidated billing regulations and gives billers a solid understanding of the rules and tips for applying them effectively.

Ambulance transfers are extremely expensive for SNFs and their Medicare Part-A covered patients. The high costs associated with transfers create a significant financial risk for SNFs,” says Barbara Reimer, consultant with the Fox Group.

If the facility uses ambulances for medically unnecessary transfers or does not bill transports correctly, they may end up on the hook for these costs. This is especially true for facilities that have high acuity patients or plan to take on more complicated patients in order to 5

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maximize profits under the new Patient-Driven Payment Model (PDPM).

“High acuity patients, particularly those with respiratory issues—they have a tracheostomy or are on ventilator—are more likely to require an ambulance for transport during their stay. Although admitting those patients can be financially advantageous, you also significantly increase the potential for additional expenses associated with ambulance transports,” Reimer says.

Mitigate the financial risks associated with ambulance transfers by gaining a solid understanding of Medicare’s coverage and consolidated billing rules for ambulance trips. and having a process for communicating internally among staff and with the patient about transfer options.

Included vs. Excluded The first step in avoiding costly consolidated billing mistakes related to ambulance transfers is to understand the terms “included” and “excluded.” This article will use the terms in the following manner: ❚ “Included” refers to the covered Prospective Payment System (PPS) ambrltc.org

items and services that are subject to or included in the consolidated bill.

The SNF is responsible for billing Medicare for these services and medications.

They must pay the outside vendor from the PPS per diem rate. ❚ “Excluded” refers to items

or services that providers should exclude from the consolidated bill (CB). The outside vendor should bill these directly to Medicare Part B.

CMS clarification on what counts as an ambulance There has been a very significant change in CMS’s approach to consolidated billing for non-ambulance transports, effective April 1, 2019, says Olga Gross-Balzano, CPA, PMP, with Berry Dunn.

“Billers need to be particularly aware of these changes because there may be charges that Medicare does not cover that they will need to be billed directly to the patient,” GrossBalzano says.

Transmittal 2176 provides regulatory guidance regarding the use of non-ambulance forms of transport, such as ambulettes or wheelchair vans.

CMS says: Medicare simply doesn’t provide any coverage at 6

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all—under Part A or Part B—for any non-ambulance forms of transportation, such as ambulette, wheelchair van, or litter van. Thus, in those situations where it’s medically feasible to convey a SNF resident by some means other than an ambulance, the transportation of

“In situations where it is medically feasible to convey a SNF resident by some other means other than ambulance, regardless of the vehicle type actually used, the charges are not covered under Medicare Part A or B—they are simply noncovered by Medicare,” Gross-Balzano explains.

er CMS regulations, the SNF must P notify the patient prior to service that the patient is responsible for the ambulance charges because Medicare does not cover the transfer.

—Olga Gross-Balzano, CPA, PMP

such a resident (regardless of the type of vehicle actually used) would neither be included within the SNF bundle nor coverable under the separate Part B ambulance benefit, but would simply be altogether noncovered by Medicare.

This clarification may cause confusion in some facilities because it is common for SNF staff to refer to any medical transport as an ‘ambulance’, no matter whether it was an actual ambulance or another type of vehicle, Gross-Balzano says.

In short, CMS clarified that ambulettes, wheelchair vans, and litter vans are not ambulances.

Because nonambulance transportation is not a service that Medicare covers, the SNF directly bill the charges to patients on a Part A stay. Per CMS regulations, the SNF must notify the patient prior to service that the patient is responsible for the ambulance charges because Medicare does not cover the transfer. The patient may choose to accept the charge or find alternative transportation, Gross-Balzano says.

Determining whether an ambulance trip is covered by Medicare Providers use ambulance services to transport patients in emergency and non-emergency situations. However, ambrltc.org

Medicare only reimburses for certain types of trips, even if a physician or other healthcare provider orders an ambulance transfer for a patient. Billers or other staff responsible for scheduling ambulance services, and the ambulance company, often have difficulty determining which types of transport are eligible, says Reimer.

The first question that SNFs should consider is, “Can this ambulance trip be deemed medically necessary?”.

The answer depends on whether another mode of transportation, such as a ambulette or wheelchair van can be used without endangering the patient’s health. If so, then the SNF may have to pay the ambulance company for the transfer, or discuss alternative transportation with the patient or family, Gross-Balzano says.

If the SNF decides that an ambulance trip is the best option, the administrator, director of nursing, and/or other designated person should determine whether the decision to use an ambulance is within Medicare’s stipulations for coverage.

“This is not a decision that the biller should make because it can have far-reaching and costly implications for the SNF,” Gross-Balzano says.

Medicare considers ambulance transports medically 7

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necessary and thus reimbursable when: ❚ The beneficiary’s condition renders the use of any other method of transportation a potential risk to the patient’s health and safety. ❚ The purpose of the

transport is to obtain a Medicare-covered service or to return from obtaining such a service.

If the designated individual determines the service in question does not meet the criteria for medical necessity, the SNF should try to plan a less-expensive transportation option, which may include using the facility’s own van, requesting an ambulette or wheelchair van from the ambulance company, or working with the patient’s family to take the resident to the appointment, GrossBalzano says.

If the appropriate person determines that an ambulance trip meets both criteria for medical necessity and therefore is reimbursable by Medicare, the next step is for the biller to determine whether the service is excluded or included in consolidated billing.

Consolidated billing for ambulance trips for services in Major category I Ambulance trips associated with major categories I.A.-I.E.

and I.G services (which are all excluded from consolidated billing) are also considered from SNF consolidated billing. If a patient requires an ambulance trip in order to receive one of the services listed in any/all of the category I subcategories, the charges are separately billable by the ambulance company, says Reimer.

The excluded category I services are: A. CT scans B. Cardiac catheterization C. MRIs D. Radiation therapy E. Angiography, lymphatic, venous, and related procedures G. Emergency services If SNFs order an ambulance trip that is not associated with these excluded categories, the SNF must pay the ambulance supplier for the service from the SNF daily rate, Reimer says.

Consolidated Billing Rules for ambulance trips for services in Major category II Ambulance transports related to major category II.A. Services excluded from consolidated billing for end-stage renal disease (ESRD) are also excluded from the consolidated bill. This includes ambulance trips for dialysis and related services, such as erythropoietin, Aranesp, and other related ambrltc.org

Education and communication are critical to managing ambulance costs Billers should proactively educate physicians and others involved in requesting ambulance services on Medicare’s coverage and consolidate billing rules for ambulance trips. Many providers may not know that Medicare only reimburses ambulance trips that are medically necessary. This requirement excludes most non-emergency ambulance transportation, such as transfers for a follow up appointment at a physician’s office. Explaining the rules and the costs associated when using an ambulance when not medically necessary can save the SNF big dollars.

If the appropriate individuals are aware of the costs associated with medically unnecessary transfers, they can arrange less-expensive transport options or avoid transfer costs all together by working with patients and their families to drive patients to appointments, says Olga Gross-Balzano, CPA, PMP, manager with BerryDunn.

In addition to education, billers should proactively communicate with clinical staff and other teams to facilitate compliant consolidated billing and manage the patient’s transport needs in the most financially effective manner possible without compromising care.

Consider the following opportunities for opening the lines of communication: ❚ Communication between departments is critical so that billers can verify the charges and confirm what should be included or excluded on the consolidated bill. ❚ In October 2019, CMS issued an alert

regarding an increase of Medicare Part B ambulance claims denials for patients covered under Medicare Part A SNF stays. Consolidated billing edit logic errors cause the errors. Although the errors

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occur when the ambulance company submits their claims, there may be an impact on the SNF. ❚ “Ambulance vendors may incorrectly bill

SNFs for the emergency transports when Medicare Part B incorrectly denies the claim. Billers should be aware of this issue and consider it while reviewing ambulance invoices,” Gross Balzano says. ❚ Reviewing invoices is an industry best

practice and ensures that you do not pay vendors for charges they should bill to Medicare Part B and prevents you from including charges on the claim that Medicare does not cover. Billers should cross-reference the trips listed on the invoices with the facility’s records to confirm the trips match. Reimer recommends confirming the following: • Name of the patient • The dates of service • The payer on the dates of service—was

is a Medicare Part-A covered day • Where the ambulance went • What clinical services the patient

received ❚ Also check the type of transportation the

facility requested against what the ambulance company actually sent. “If the vendor provides a higher-level or more costly level of transportation, then the facility should not be charged for the more expensive transport,” Gross-Balzano says. ❚ At admission, billers should flag patients

who will go out for services that the SNF will potentially have liability for ambulance transport, such as those coming to the

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SNF after surgery. Proactively speak with the care team and the person who plans ambulance transports about these patients. Remind them of Medicare rules for coverage and when it is financially advantageous to use nonambulance services, says Barbara Reimer, consultant with The Fox Group. ❚ You should also keep a close eye on pa-

tients who are scheduled for a CT or MRI and work with the care team. “Try to get the patient’s physician to write the order to send them to a hospital-based imaging center. If they go to a free-standing center, it does not fall under the consolidated billing rules. Even through the CT or MRI are billable to Medicare Part B by the imagining center, the transport does not meet

diaslysis related services for ESRD patients.

Billers should exclude the dialysis or related services when services are provided in a renal dialysis facility, including ambulance services listed under major category I. Major category II.B. Hospice care for a beneficiary’s terminal illness also has consolidated billing implications for ambulance trips.

“Many providers are not aware that once a patient elects a hospice benefit, ambulance transports after that effective date, is the responsibility of the hospice provider,” GrossBalzano says.

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the requirements, and would be the SNF’s responsibility,” says Reimer.

Communication with ambulance vendors is also vital to controlling costs. SNFs should revisit their contracts with ambulance vendors to secure the best rates possible, especially if the Medicare patient population in your facility requires many nonemergency transport calls, Reimer says.

Notifying ambulance companies that patients are on a Part A stay can also reduce issues related to consolidated billing or mistaken payments for trips that the SNF is not responsible for paying. The notification will help increase the likelihood that the ambulance company will bill Medicare Part B when appropriate rather than including the trip(s) on the invoice to the SNF, Gross-Balzano says.

Select bill types 81S and 82X on the UB04 to identify hospice services for terminal illness. These services are excluded from the SNF consolidated bill, and the licensed hospice provider should bill Medicare for any ambulance trips related to the terminal condition for patients in the midst of a Part A stay.

the medical services that fall in the following four category III subsets: ❚ Certain chemotherapy drugs ❚ Chemotherapy administration ❚ Radioisotopes and their administration ❚ Certain customized prosthetic devices

Consolidated Billing Rules for ambulance trips for services in Major category III

Consolidated billing for major category III can be confusing for providers because many of the services themselves are excluded from the consolidated bill but billers should include the ambulance transport in the consolidated bill.

To determine whether a service is excluded in the

Ambulance services related to major category III are included in SNF consolidated billing. The SNF is financially responsible for transport to and from providers who deliver

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consolidated bill, search the SNF Part A MAC Update file for the HCPCS code. If the code appears in the file, then it is excluded from the bill.

You can download the file, which are updated quarterly, from the CMS website—www. cms.gov/Medicare/Billing/ SNFConsolidatedBilling/ index.html.

Medicare-covered ambulance services excluded from consolidated billing There are several additional specific circumstances under which a beneficiary may receive Medicare-covered ambulance services that you should exclude from consolidated billing: ❚ The ambulance trip is to

the SNF for admission.

❚ The ambulance trip oc-

curs after discharge from the SNF and conveys the beneficiary from the facility to the beneficiary’s home, where the individual will receive services from a Medicare-participating home health agency under a plan of care. ❚ The ambulance trip is

to a hospital-based or non-hospital-based endstage RDF for the purpose of receiving dialysis and related services that are excluded from consolidated billing. ❚ The ambulance trip is from

the SNF to a Medicareparticipating hospital or critical access hospital (CAH) for an inpatient admission.

❚ The ambulance trip occurs

after discharge or other departure from the SNF and conveys the beneficiary to any destination other than another SNF. This is excluded only if the beneficiary does not return to that or another SNF by midnight of that same day, says Gross-Balzano. ❚ The ambulance service

conveys a beneficiary to a hospital or CAH and back to the SNF for the specific purpose of receiving emergency or other excluded outpatient hospital services.

In these cases, the ambulance company—not the SNF— should bill Medicare Part B separately for the service. The SNF should not pay the supplier from the SNF daily rate, Reimer explains.

Ambulance trips must have the following in common with a qualifying category I or II.A. service to be considered a related (and therefore excluded) transport: ❚ Place of delivery ❚ Billing provider ❚ Line item date of service

(LIDOS) To avoid awarding duplicative payments for excluded ambulance trips, Medicare compares LIDOS entries on outpatient 10

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claims submitted by different providers when they relate to the same beneficiary and have overlapping time frames—a tactic that ensures that the insurance plan does not reimburse for services that were already included in the SNF daily rate (i.e., accounted for on a consolidated bill) if they appear again on a separate claim.

Medicare-covered ambulance services included in consolidated billing As detailed previously, if an ambulance is needed to facilitate the provision of a category III service, the trip should be accounted for in the SNFs consolidated bill. Ambulance trips for category III services are not excluded from CB, regardless of whether they meet the medical necessity criteria.

In addition to ambulance transports that correspond with category III services, the following trips are also included in SNF CB when rendered to a beneficiary during a Part A SNF stay: ❚ A trip to facilitate a patient’s transfer from one SNF to another before midnight of the same day ❚ A trip to or from a diag-

nostic or therapeutic site other than a hospital or RDF (e.g., an independent diagnostic testing facility, 11

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cancer treatment center, radiation therapy center, wound care center, or physician office) Because the SNF will account for the above-stated trips in its consolidated bill, it should reimburse the ambulance service provider from the SNF daily rate payment it receives from Medicare based on this claim.

ambulance transportation, such as transfers for a follow up appointment at a physician’s office.

If the appropriate individuals are aware of the costs associated with medically unnecessary transfers, they can arrange less-expensive transport options or avoid transfer costs all together by

t admission, billers should flag A patients who will go out for services that the SNF will potentially have liability for ambulance transport, such as those coming to the SNF after surgery.

—Barbara Reimer

Education and communication are critical to managing ambulance costs While it is important for billers to understand the ins and outs of consolidated billing for ambulance, it is helpful to educate physicians and others involved in requesting ambulance services on Medicare’s rules.

Doing so can prevent costly mistakes related to ambulance transfers.

For example, many providers may not know that Medicare only reimburses ambulance trips that are medically necessary. This requirement excludes most non-emergency

working with the patient and their families to drive the patient to a followup appointment, says Gross-Balzano.

At admission, billers should flag patients who will go out for services that the SNF will potentially have liability for ambulance transport, such as those coming to the SNF after surgery. Proactively speak with the care team and the person who plans ambulance transports about these patients. Remind them of Medicare rules for coverage and when it is financially advantageous to use nonambulance services, Reimer says. ambrltc.org

Keep a close eye on patients who are scheduled for a CT or MRI. “Try to get the patient’s physician to write the order to send them to a hospital-based imaging center. If they go to a free-standing center, it does not fall under the consolidated billing rules. Even through the CT or MRI are billable to Medicare Part B by the imagining center, the transport does not meet the requirements, and would be the SNF’s responsibility,” Reimer says.

the patient is on a Part A stay.

That way, the ambulance company will be more likely to bill Part B when appropriate rather than including the trip(s) on the invoice to the SNF, GrossBalzano says.

Offset some charges for ambulance trips by charging the administrative processing fee that CMS allows SNFs to charge vendors.

“Reduce the amount you owe vendors—not just ambulance companies—by charging a reasonable administrative fee.

“As a best practice, the facility administrator, director of nurses, or another designated person should review invoices from ambulance companies and match them to the facility’s logs. It’s a critical review because you do not want to include charges on the consolidated bill that are not covered

by Medicare. You want to bill them to the appropriate entity,” Gross-Balzano says.

Ambulance companies may not always have a strong understanding of SNF consolidated billing, so Reimer recom-

It’s a critical review because you do not want to include charges on the consolidated bill that are not covered

by Medicare. You want to bill them to the appropriate entity.

—Olga Gross-Balzano, CPA, PMP

mends confirming the following: ❚ Name of the patient ❚ The dates of service ❚ The payer on the dates of

service—was is a Medicare Part-A covered day ❚ Where the ambulance

went Communication with ambulance vendors is also vital to controlling costs associated with these transfers. Work with ambulance vendors to secure the best contract possible, especially if you know your Medicare patient population requires many transport calls, Reimer says.

Additionally, ensure the proper process are in place to notify ambulance suppliers that

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Billers’ work is not free, accounts payable staff work is not free, so CMS allows you to apply a charge for processing the invoice,” Gross-Balzano says.

Review bill Communication between departments is critical so that billers can verify the charges and confirm what should be included or excluded on the consolidated bill.

❚ What clinical services the

patient received Also check the type of transportation the facility requested against what the ambulance company actually sent.

“If the vendor provides a higher-level or more costly level of transportation, then the facility should not be charged for the more expensive transport,” Gross-Balzano says.

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A NEW WAY TO USE RESTORATIVE NURSING

Opportunities to incorporate restorative nursing into your care plan The Patient-Drive Payment Model (PDPM) emphasizes the need for the interdisciplinary team (IDT) to develop an appropriate plan of care for each patient. The IDT should consider whether restorative nursing should be a part of the patient’s treatment plan, especially now that PDPM provides a revenue opportunity for including restorative nursing.

Nursing drives restorative programming for each patient.

Restorative nursing addresses recovery or improvement in function and when possible, restoration to a previous level of health and well-being.

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In RUG-IV, many IDTs implemented RNPs for patients at the end of the stay after they met their therapy goals.

PDPM’s reimbursement for restorative nursing allows MDS nurses, nursing staff, and therapy to adopt a new way using restorative nursing from the beginning of the patient’s stay, says Jennifer Gross, BSN, RN-BC, RAC-CT, CPHIMS, senior healthcare specialist with PointRight Inc. For example, a patient comes to the SNF for a Medicare Part A stay after a fall and fracture, and he has a loss of mobility. The care plan

can include therapy to address walking, gait, and transferring, but the care team may also use restorative nursing treatments to help the patient practice those skills.

“You can’t really effectively restore function for patients if they’re only getting therapy once a day. RNPs supplement therapy and help patients achieve their goals more quickly,” Gross says.

In addition to providing clinical benefits for the patient, RNPs also provide a structured way for providers to manage and capture how the patient performs activities outside of

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their time in the therapy department. This gives the IDT a clearer picture of their patients’ progress toward goals so that they can adjust the care plan as necessary, Gross adds.

As long as it is clinically indicated, you always want to maintain that minimum of six restorative nursing visits per week for 15 minutes in order to continue receiving payment for it.

In PDPM, consider all patients in a look back window because you might have to perform an interim payment assessment (IPA) for another reason at any time, and you want to capture that RNP reimbursement, says Melissa Sabo, OTR/L, CSRS, chief operating officer with Gravity Healthcare Consulting.

RNPs are also a great option if a patient who is admitted does not meet the criteria for any of the other four nursing categories, Sabo says Although the opportunity to provide restorative nursing and therapy concurrently may be the best treatment for some patients, remember that the treatment must be patient-centered, meaning that it is not the right treatment for all patients, says Rosanna Benbow, RN, CCM, CIC, DNS-CT, RAC-CT, president of Leading Transitions Post Acute Care and Staffing.

“Some patients will not want to see a restorative aid, especially if they’re working with 14

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more than one therapy discipline. Restorative and therapy may be too much for them,” Benbow says.

RNPs can also support a safe discharge because they help patients practice skills safely and independently, which prepares them to successfully return and stay at home.

“Restorative programing is a great option for patients who are more fragile and may need more time to practice what they learned in rehabilitation/therapy before they go home. The extra time may prevent hospital readmissions because they can get stronger in those skills. Or, if they decline, we can call the therapist back in until you’re comfortable enough to discharge them,” says Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RACMTA, president and CEO of Celtic Consulting.

SNFs can also use RNP when medically necessary to help patients maintain a skilled-level of care if the IDT determines the patient does not need skilled therapy treatment, McCarthy says.

Chapter 8 of the Medicare Benefit Policy Manual describes the role of restorative nursing when it is used to meet the skilled level of care requirements: “In instances when a patient requires a skilled restorative

nursing program to positively affect his functional well-being, the expectation is that the program be rendered at least 6 days a week. (Note that when a patient’s skilled status is based on a restorative program, medical evidence must be documented to justify the services. In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)”

Additionally, RNPs are a great tool for the IDT to collaborate on discharge goals, especially if the number of days the resident can stay in the SNF are limited by an accountable care organization or managed care insurer’s plan. In these cases, it is often in the best interest of the resident to include a RNP that expands the therapy coverage beyond the therapist.

During the off-shifts, nursing assistants can continue to work with residents on the compensatory strategies the therapist teaches them.

The reimbursement opportunity PDPM provides for restorative nursing reflects CMS’s shift from volume to value-based care. Restorative programs are now in the spotlight, but patients should only receive restorative nursing treatments if it will enhance their outcomes. ambrltc.org

MEASURING SUCCESS

Key performance indicators under PDPM Now that we’ve survived PDPM preparation and its official implementation on October 1, 2019, the conversation is shifting to “how do I know if I’m succeeding?” Education about success under the new payment model should be viewed as fluid and ongoing. The best way to measure your success is to first define it. While this will vary across facilities, if you have the following items completed right now, you’re likely in good shape: ❚ The MDS department and IDT have received specific training on updates to the RAI manual.

rely on to tell them whether they are on the right track to achieve the ultimate goal of providing quality care, lowering costs, and increasing reimbursement.

Sam S. Phillips, CPA, MBA, RAC-CT at WalkerPhillips Healthcare Consulting, a company that focuses solely on reimbursement for SNFs, has seen a lot of long-term care facilities consolidate over the last 10 years. This has resulted in a decrease in the “mom and pop” facilities and an increase in larger companies that can offer more diversified services and that have more resources

to help them prepare for the new payment model. “I think facilities that are prepared will do very well financially this year,” he says.

Phillips predicts that CMS will end up reimbursing facilities at a higher rate than anticipated, however, and will pull back on reimbursement beginning next October when they realize the new model isn’t budget neutral. “Only the best facilities will do well at that point,” he says.

If Phillips is right, high performance over the next year will be critical for facilities that want to continue to thrive in 2020.

❚ Your policies, procedures,

and processes have been updated to incorporate practices that support PDPM. ❚ The nursing department

has received a refresher course on Medicare eligibility requirements and how to properly document skilled services. ❚ Terms and pricing in re-

hab contracts have been finalized.

Moving forward, many SNFs are wondering what key performance indicators (KPI) they can 15

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ambrltc.org

To prepare for this predicted monetary pull-back, Phillips recommends SNFs: ❚ Become very familiar with the types of residents they serve and how acuity aligns with profitability

take the money back if they find inconsistent information, paid claims are not always representative of successful operations.

“You have to dig much deeper than that and a key place to start is outcome trends.”

level of group and concurrent minutes will also look suspect.

If facilities find that these kinds of trends are occurring, they need to perform a root cause analysis to determine why, says Arellano. “Identifying

❚ Perfect the initial assess-

ment, which will be the payment driver moving forward ❚ Ensure that resident

outcomes are optimal so the facilities become the provider of choice in their geographic area Stefanie Corbett, DHA, post acute regulatory specialist for HCPro, adds that, “the rulestick of PDPM success should include the quality of documentation in the medical record, MDS assessment accuracy and timeliness, and patterns related to claims errors and denials.”

Using these general goals as a guide, the following sections provide an in-depth look at specific KPIs that can be used to measure success under PDPM.

Change in resident characteristics Maria Arellano MS, RN, RAC-CT, senior healthcare specialist at PointRight, Inc. warns facilities against looking at paid claims as an indicator of success. While she admits that getting claims paid is important, because CMS has the right to 16

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MS has been very upfront with us that the C switch to PDPM was necessary because certain players in the industry manipulated the former payment system.

—Maria Arellano MS, RN, RAC-CT, senior healthcare specialist at PointRight, Inc.

A sudden change in your resident characteristics after October 1, for example, is a better indicator that you might be coding to pad reimbursement, which will trigger a red flag to CMS. “CMS has been very upfront with us that the switch to PDPM was necessary because certain players in the industry manipulated the former payment system in this same way, so we want to make sure we don’t repeat that behavior,” says Arellano.

Characteristics that receive higher reimbursement under PDPM such as swallowing disorders and mechanically soft diets are at particular risk of being scrutinized if they increase dramatically. A significant drop in therapy minutes or a sudden shift to using only group or a higher

these trends is like seeing the red light flash on your dashboard. It indicates a potential problem that should be investigated further to understand why it is occurring.”

It might just be that the documentation to support the trend is missing. “For example, if I find that a resident is consistently going over the 25% threshold for group and concurrent therapy, I may also find that the individual actually does better in a group. It can be encouraging or motivating to do therapy with somebody versus by yourself, so just make sure that you document that reasoning,” says Arellano.

Declines in function levels and mobility Once you’ve evaluated trends with therapy minutes, ambrltc.org

you can take it a step further by looking at changing outcomes, especially in the first 90 days of the resident’s stay.

“If you have an increase in residents with functional decline and your therapy minutes also decreased, you’re telling CMS that not only have you decreased therapy, but now your outcomes are also declining,” says Arellano.

Function and mobility levels are important KPIs to evaluate to determine success under PDPM because the whole premise of value-based care is that CMS pays for both value and quality of care, not just for the service being provided, says Arellano.

It’s important to determine correlations between decreased services and declines in function, especially when it comes to the less-profitable, but still very essential service of therapy.

Unfortunately, since PDPM’s implementation on October 1, thousands of physical, occupational, and speech language therapists working in SNFs have experienced wage decreases or layoffs, revealing an approach shared by many SNFs to dramatically decrease these services, which have lost their financial appeal under PDPM. While those employees affected have been quick to contact CMS and the news with their concerns, the 17

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potential impact on residents has been less publicized.

According to a recent Change.org petition to the United States Department of Health and Human Services, however, residents are being negatively affected by decreases in therapy, which is often a result of cost-saving attempts made by administration. “Greedy rehab and nursing home executives are being given permission to interfere in patients’ therapy plans, and it’s causing real harm. Our jobs are being threatened when we object to treating patients only in a group or if we provide ‘too much’ therapy. Some patients are only getting 15 minutes of therapy scheduled,” writes Susan Sullivan, the creator of the petition and an occupational therapist.

Other therapists have spoken out as well with concerns not only about their jobs, but for the resident populations they serve.

Arellano warns SNFs not to make decisions that are “penny wise and pound foolish,” such as reducing a resident’s length of stay just to get him or her out the door before it comes time for that 2% drop in reimbursement to take effect.

Phillips believes SNFs could have increased lengths of stay under PDPM. He believes PPS rate tapering could be more

significant than what we see under PDPM and recommends measuring potential profitability for each resident’s stay. He says a facility might benefit by categorizing patients by clinical type.

“Under RUG-IV we really got away from looking at profitability that way because SNFs were trying to avoid costs like high-dollar IVs but under PDPM, where reimbursement is determined by resident characteristics, SNFs that perform this kind of analysis may be surprised by what they find and can better determine which type of resident they want to target to find their niche.”

“If you think about it, sometimes the drop in therapy reimbursement is just four or six dollars a day, and that person may need just one or two more days to get strong enough to succeed in their next setting versus, you know, you rushed them out too quickly to save a few bucks and now you’re facing readmission penalties,” says Arellano.

Sharing is caring Many SNFs are signing on to risk-sharing opportunities to help them perform better under PDPM. In fact, SNFs may be missing an opportunity by not approaching hospitals about a risk-sharing agreement.

It works like this: PDPM reimburses more for higher ambrltc.org

acuity patients, meaning SNFs need to diversify their services to maintain financial stability.

A hospital’s goal is to treat a patient and hand him or her off as quickly as possible to a facility with high-quality ratings and that can also provide the services necessary to treat sicker patients. If SNFs can establish a partnership with the hospital, it means more beds filled and more control of how individuals move along the care continuum. This ideal scenario is no doubt a result of PDPM’s position as a step toward a post-acute care site-neutral payment system.

Phillips says something that can make a SNF more appealing to a hospital is if they specialize in treating a particular condition such as COPD. “Facilities that find a niche have the potential to draw from a larger footprint,” he says.

SNFs can also enter into a risk-sharing contract with a third-party therapy contractor, a move that almost all of Phillips’ clients have made.

There are several approaches that SNFs can take when negotiating a risk-sharing contract with a therapy provider. Some common approaches include: ❚ SNF pays therapy contractor per minute ❚ SNF pays therapy contrac-

tors per day 18

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❚ SNF pays therapy contrac-

tor a percentage ❚ Bringing therapy services

in-house Phillips says he plans to re-evaluate his clients’ rehab contracts in three to six months. Almost all of his clients ended up with a percentage of PDPM rehab revenue contract arrangement (where the SNF pays the therapy contractor a percentage of the SNF’s PDPM rehab reimbursement). “We did not have a lot of real-time data when we drafted the contracts initially, so I will be interested to see how outcomes ended up with the percentage-based contracts in place. Some folks have really cut their rehab back.

They better make sure they are getting good outcomes or they may get a visit from CMS.”

Getting enough information during the 5-day assessment A big concern for SNFs has been not only understanding PDPM’s requirements and integrating them into their

processes, but actually operationalizing the payment model’s requirements. One significant change requires SNFs to get a lot more information up front in order to accurately complete the 5-day assessment during the preadmission phase.

“You can’t use the 14-day assessment to correct mistakes made on the 5-day assessment anymore. So this KPI would be looking at whether enough information was collected during the preadmission assessment and a SNF might do that by extracting a random sampling and auditing a few charts to see if the necessary information was collected to ensure success further down the road,” says Arellano.

Having meetings with the IDT (including your MDS coordinator, director of nursing, and administrator) can be useful to make sure everyone is on the same page, and to fill in the gaps or inconsistencies. In Corbett’s opinion, the triple check process will help with this as an internal audit function. ambrltc.org

Who should be asking the question of which areas need improvement?

In Arellano’s experience, “you can lead from anywhere.”

If everyone is held accountable, the conversation about improvement can be an open discussion, rather than something that just one role is responsible for. Traditionally the MDS coordinator in a SNF has been held accountable for a lot of different things, but if a facility can work together, it takes the pressure off and allows for teamwork.

Learning from quality measures Quality measures (QM) are an invaluable KPI to determine success under PDPM because QMs are the one consistent standard that CMS is measuring facilities against. Reviewing QMs in real-time is a great way to notice subtle changes before they become publicly recorded so you can go back and identify which residents are falling into which categories, and why.

Arellano says that CMS will be paying extra close attention to rehospitalization measures and functional measures, both of which determine whether a facility provided the right amount and type of services.

And proving that means having thorough nursing documentation and being able to describe the need for rehabilitative care.

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Additionally, SNFs should always me mindful of the national and regional Medicare A and B CERT test results and claims error rates. They should also compare their survey history to average results in their states, says Corbett.

Determining key financial indicators with the Medicare cost report By analyzing your Medicare cost report, SNFs can accomplish the following: ❚ Analyze year-over-year occupancy, payer mix trends, or Medicare utilization review ❚ Make operational changes in areas with large variances ❚ Compare your SNF’s trends with those of your peers’ using the data from CMS’s Healthcare Cost reporting Information System (HCRIS).

Filing accurate cost report data and understanding the data available for benchmarking are essential to successfully using your cost report and HCRIS for creating internal benchmarks to measure your facility’s performance. Key financial indicators found on your cost report that could result in revenue opportunities under PDPM include the following: ❚ How therapy costs have changed under PDPM: Use your cost report to

evaluate how therapy costs have changed since the shift from RUG-IV to PDPM. You should also look at how your costs and therapy delivery compare to other providers. ❚ Therapy cost to charge ratios: Is your therapy program operating optimally compared to other facilities in your area or across the country? ❚ Average length of stay: Because PDPM introduces variable per diem adjustments for physical and occupational therapy after day 20, and nursing therapy ancillary (NTA) components after day 3, looking at your average LOS compared to other facilities can help drive operational decision making. If your average LOS varies greatly from other facilities, you’ll want to understand why, and determine how that’s impacting reimbursement. ❚ Per-day operating data: Cost reports document data on your ancillary costs per resident day, direct care hours per resident per day, and your Medicare profit or payment per day. Compare these costs to costs under the previous payment model (RUG-IV) and use the HCRIS report to compare against your peers. ambrltc.org

EXPERT Q&A The year ahead: What will it take for SNFs to succeed in 2020 SNFs experienced unprecedented change in 2019, and 2020 is shaping up to be equally as transformative for the industry. AMBR asked industry-leading experts to weigh in on what emerging trends and new regulations they expect to see in 2020 and where SNFs should focus to be successful in the new year.

From PDPM reviews and audits to proposed regulations with potentially weighty financial implications, new market models, and a focus

MP | A remarkable number of skilled nursing facility (SNF) companies are also becoming managed care companies and developing Institutional Special Needs Plans (ISNPs). This is the start of a very important effort for SNFs that will help them avoid being commodities in a value-based payment world. Instead, they will run the show. There are currently 44 SNF-owned ISNPs in the country, and that number will continue to increase in 2020 and beyond.

on quality and patient outcomes, SNFs should

BZ | Doing more with less has always been a

prepare for another whirlwind year.

challenge for SNFs. This will not change in 2020, but how we capture the “less” portion of the scenario will be more difficult. Cross-training management staff in financial and clinical areas will be crucial as the team will need to communicate and work more closely than ever before. I’ve seen facilities send their business office managers and admissions/marketing directors to ICD-10 training as well as core knowledge classes. The more well-rounded your team is in their knowledge base, the better positioned you will be.

Meet the experts: ❚ Mark Parkinson, president and CEO,

ACHA ❚ Becky Ziviski, CPA LNHA, CEO, Profit

Without Census and author of “Profit Without Census? A Nursing Home Administrator’s Guide to Profitability by Department” ❚ Maureen McCarthy, RN, BS, RAC-MT,

QCP-MT, DNS-MT, RAC-MTA, president and CEO of Celtic Consulting ❚ Todd Selby, healthcare attorney with Hall,

Render, Killian, Heath & Lyman, P.C. ❚ Jessie McGill, RN, RAC-MT, curriculum

development specialist for AANAC

Q | What trends do you expect to see the industry experience or adopt in 2020?

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MM | It will only be a matter of time before the RAC auditors will request medical records to review our accuracy and compliance with PDPM coding. The review process will likely focus on skilled documentation resulting from payer denials (i.e., does your documentation match the skilled services you are billing for?). In the previous RUG-IV system, the majority of Medicare-covered residents fell into rehab categories, which may ambrltc.org

have minimized the importance of the nursing documentation. Now that PDPM is in place and the focus is on resident diagnoses and conditions, the documentation from our nursing staff will need to be significantly improved. Improving documentation should be on the forefront for most SNFs in 2020.

MS will continue to focus C on over-utilization of therapy because the goal of PDPM is to move away from therapy as the driver for reimbursement. —Todd Selby, healthcare attorney with Hall, Render, Killian, Heath & Lyman, P.C.

TS | I think you will continue to see challenges and opportunities under PDPM. Facilities that can get their arms around the ICD-10 admitting diagnosis and facilities that treat medically complex patients could see an upside from PDPM. However, I do fear that there will be an audit focus on nursing documentation due to the

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potential upside in payments for the nursing component under PDPM. I also fear that CMS will continue to look at both over-utilization and under-utilization of therapy. CMS will continue to focus on over-utilization of therapy because the goal of PDPM is to move away from therapy as the driver for reimbursement. CMS has already stated they will look at facilities who drastically reduce therapy. Facilities have a duty to provide care that the resident requires, so if the resident requires therapy, the facility must provide therapy regardless of the reimbursement system.

I also expect to see more consolidation and facility closures. There have been lots of consolidation of long-term care providers in the last few years. I think that trend will continue given the amount of private equity money that is being invested in the senior living sector. I also think you will see smaller facilities close due to obstacles they will face with PDPM and Medicaid Fiscal Accountability Rule (MFAR) that CMS recently proposed. I will address this rule in more detail below.

Last, SNFs need to prepare to comply with the Conditions of Participation §483.85. Although November 28, 2019 marked the implementation date of Phase 3 of the Requirements of

ambrltc.org

Participation (ROP), CMS has issued little or no guidance for the ROPs addressing comprehensive care plans, trauma-informed care, infection preventionists, training, and compliance and ethics program. However, on November 22, 2019 CMS announced that it will finally issue updated interpretive guidelines for these ROPs in the second quarter of 2020. CMS will also release survey training guidance regarding the Phase 3 ROPs. Although the Phase 3 ROPs are in effect, CMS will not enforce them until it issues the interpretive guidance. Lack of interpretive guidance is problematic for two reasons. One, CMS has had over three years to publish interpretive guidance on the Phase 3 ROPs and they have yet to do so.

Secondly, although CMS says it will not enforce the Phase 3 ROPs until it issues interpretive guidance, they are in effect and there are no assurances that surveyors will not cite deficiencies for the violation of the Phase 3 ROPs.

JM | I expect many providers to focus on expanding staff competency to enable SNFs to take more clinically complex residents. This will also improve the SNFs ability to treat residents with acute conditions at the SNF rather than having the resident readmitted to the hospital for treatment.

I also expect to see the role of the nurse assessment coordinator (NAC) evolve into a care coordinator or case-manager role, which focuses on resident outcomes, discharge goals, and preventing rehospitalizations.

Lastly, I expect that later in 2020, SNFs will become more focused on overall resident outcomes. For example, many providers are currently adjusting therapy services, encouraging more group therapy, increasing the use of restorative programing, and making other changes. It may be too soon to identify whether these changes will maintain positive resident outcomes or if these residents will experience longer lengths of stay, rehospitalizations, or other negative results.

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Q | What new rules or regulation changes do you expect to see from CMS in 2020?

MP | With respect to CMS, 2020 will be about PDPM and the recently proposed rule on Medicaid inter-governmental transfers (IGTs). With its actions, CMS will decide the future of both Medicare and Medicaid. The sector will continue to work with CMS on the PDPM to ensure that implementation is working for residents and providers. On the Medicaid side, the sector will undertake a very large effort to convince CMS that provider assessments and upper payment limit programs are vital to provide the funds to care for our millions of residents.

nytime new regulations A are initiated, other processes such as CHOPs and CHOWs face increased delays.

—Becky Ziviski, CPA LNHA, CEO, Profit Without Census

BZ | Regulatory changes have been part of the SNF environment for years, and I don’t foresee that changing anytime in the near future.

However, the incredible number of SNFs closing or going bankrupt as a result of poor management or absentee management has not gone unnoticed by the government. Increased scrutiny for SNF buyers as well as the re-enactment of the Housing and Urban Development Real Estate Assessment Center’s program are currently in the works. Anytime new regulations are initiated, other processes such as CHOPs and CHOWs face increased delays.

MM | Hopefully, CMS will expand the clinical mapping to include more diagnoses relevant to a ambrltc.org

SNF population. For instance, a resident admitted with a GI bleed (internal bleeding) does not currently map to PDPM. Therefore, if no other diagnoses affect the focus of treatment for the skilled stay, the resident may not qualify for a Medicare-covered stay. CMS will likely scrutinize the case mix groupings (CMG) SNFs submit for reimbursement. CMS will likely watch how providers utilize the Interim Payment Assessment (IPA). If CMS imposes constraints on how SNFs can use this assessment, it may change providers’ ability to recalculate the CMG that can be billed. Additionally, managed care insurers and state Medicaid programs may evaluate whether a PDPM case mix index system would be more beneficial than a RUG-based system. Beyond 2020, we may see some states move to a PDPMbased acuity system.

I f CMS imposes constraints on how SNFs can use this assessment, it may change providers’ ability to recalculate the CMG that can be billed.

—Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RACMTA, president and CEO of Celtic Consulting

TS | CMS proposed a rule November 18, 2019 called the Medicaid Fiscal Accountability Rule (MFAR). MFAR targets states with Medicaid supplemental payment programs. Although MFAR is somewhat complicated in design, consider the following simple explanation of the supplemental payment program: It allows a non-state government owned (NSGO”) provider (i.e., a county hospital or hospital district) to lease or own a long term care facility. The NSGO makes what is called an intergovernmental transfer to the state 23

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Medicaid program, which allows long term care facilities to access Medicare Upper Payment limits as a means of reimbursement rather than traditional Medicaid reimbursement.

Not all states have supplemental payment programs, but MFAR can significantly impact those that do have these payment programs. CMS proposed sunsetting all existing supplemental payment programs. If MFAR becomes final, states would have 2 to 3 years to become compliant by putting new supplemental payment programs into place. MFAR is a big deal for SNFs because it offers greatly enhanced reimbursement to long term care facilities in states where supplemental payment programs exist. If supplemental payment programs go away or states cannot comply with MFAR once it becomes final, it is highly likely you will see closures of long-term care facilities.

MFAR could also impact states that have tax waivers for providers. This is important in that virtually every state has a provider tax or a provider tax with a waiver. Under federal law, long term care providers can create provider taxes up to 6%. The MFAR proposed rule will change the provider tax mechanism and long-term care facilities will have 3 years to comply and apply for waivers regarding provider taxes.

JM | The FY2019 SNF PPS Final Rule substantially increased the number of items that will be added to the MDS item set in October 2020.

Many of these items collect data related to the SNF Quality Reporting Program (QRP). I expect that CMS will continue to focus on expanding the SNF QRP program and making data available to the public via Nursing Home Compare.

CMS adequately warned that they will monitor for substantial changes in therapy provision in PDPM. I expect to see CMS follow through with this warning and audit SNFs that show a drastic change in therapy provision, especially in SNFs that saw worse outcome measures. In addition, I believe CMS will increase audits for SNFs who ambrltc.org

exceed the 25% limit on group and concurrent therapy.

Lastly, I expect to see the Medicare Administrative Contractors (MACs) begin audits on PDPM claims. Because ICD-10-CM codes are a significant determinant of the HIPPS code, I expect to see increased audits on active diagnoses and the documentation to support the accuracy of these codes.

Q | What financial or compliance areas should SNFs focus on to be successful in 2020?

MP | The success or failure of most SNFs in 2020 will depend on the successful implementation of PDPM. Operators who prepared last year appear to be doing well this year. Those that did not are struggling. Those that focus on patient outcomes and quality will thrive. Those that see PDPM purely as a financial opportunity will not.

BZ | As reimbursement models and contracts have changed, so have the cash flow positions of many facilities. Not only have some reimbursement models resulted in a decrease in revenue, but some have longer claim payment time frames.

Add these to census challenges, and it can be a recipe for cash flow nightmares.

Now more than ever, it’s imperative that the Administrators/CEOs provide oversight for each department and ask the right questions.

Efficiently running departments is crucial to maintaining the financial health of facilities. Are MDSs being submitted timely and do they accurately reflect the acuity of your population? Are your A/R and A/P team members working together on cash flow timing? How efficient is your kitchen, housekeeping or laundry department? Make sure you fully understand your operations and involve managers in solutions-based conversations about their departments and how they affect operations as a whole.

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It’s also a great time to revisit your debt structure. Interest rates have changed over the last several years, making it a great time to call your lender about potentially refinancing or consolidating your debt. Take advantage of more favorable interest rates or potentially spread the loan over a longer period of time to reduce monthly capital expense.

he success or failure of T most SNFs in 2020 will depend on the successful implementation of PDPM. —Mark Parkinson, president and CEO, ACHA

MM | I would expect a CMS announcement that RAC auditors will verify the primary diagnosis in I0020B to the diagnoses in the hospital stay, or the condition responsible for the admission to the SNF. In order to avoid the appearance of non-compliance, facilities should verify accurate diagnosis coding as compared to the medical record. In addition, documentation should be reviewed on a routine basis to ensure that it supports that skilled services are being provided.

This will be a key component to revenue integrity.

Additionally, your PDPM review process should include a review of the remittance advices to be sure they were paid correctly by the MACs. There have been many errors and issues with the technical specifications between software vendors and MACs, so providers should ensure they receive all the reimbursement due to them for the resident’s stay. For example, you will want to confirm that the non-therapy ancillary component or PT/OT component calculated correctly on the appropriate days. Linking the clinical component to the financial component has always been a focus and will likely continue to be far past 2020. ambrltc.org

TS | I think another compliance issue flying under the radar is that starting October 23, 2019 CMS will now put alert icons on Nursing Home Compare when long term care facilities receive citations for abuse, neglect, exploitation, and involuntary seclusion of residents. Long term care facilities will receive an alert icon if they are cited for a G (harm) level deficiency in the last year or a D (potential for harm) in two consecutive years. The survey component of the 5-star program will be capped at 2 stars for facilities that receive an alert.

hile SNFs have W historically only looked at the MDS and the HIPPS code for Medicare reimbursement, there are now more items which influence the Medicare rate. —Jessie McGill, RN, RAC-MT, curriculum development specialist for AANAC This could be very problematic and could unfairly target long term care facilities because the definitions of abuse and neglect are very broad and subject to liberal interpretation by state surveyors. Given these definitions are overly broad, it is highly likely that long term care facilities will receive alert icons. The fact that long term care facilities can receive an alert icon merely for a level D deficiency where there is only a potential for harm is very troubling. The definitions of abuse and neglect need to be tightened or there will be lots of facilities with alert icons going forward.

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It should also be noted that long term care facilities are the only CMS-regulated provider not required to report consumer satisfaction. It would seem having consumer satisfaction included on Nursing Home Compare would be much more valuable to consumers than a subjective icon on whether a long-term care facility has been cited for abuse.

JM | I believe that for overall and ongoing financial success, the SNF must begin to look at the overall picture and not just at specific residents. While SNFs have historically only looked at the MDS and the HIPPS code for Medicare reimbursement, there are now more items which influence the Medicare rate. We now must also look at documentation and reporting of SNF QRP data, which can result in a 2% reduction of the Annual Payment Update (APU) for the effective program year if the threshold is not met. In addition, your Medicare rate will be adjusted by the SNF Value-Based Program (VBP), which could either increase or decrease your overall Medicare rate based on a readmission measure. Without this overall focus on reporting SNF QRP data and preventing rehospitalizations, SNFs may endure devastating cuts to their Medicare rates that are implemented for the entire fiscal year.

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