medicare: survive today and prepare for tomorrow monday october 11, 2010 1
TRANSCRIPT
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Medicare:Survive Today And
Prepare For TomorrowMonday October 11, 2010
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Today and Tomorrow Is All About Health Care Reform
Elise SmithVice President, Finance Policy
American Health Care Association
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Health Care Reform Balancing Act
Coverage Expansion
Cost Containment
Improvement in Quality
Cost Containment Strategy • Direct -- Continue to Address and Improve Current
Methodologies– PPACA holds down increases in adjustments to provider payments in
all categories– Silo coverage and payment methodologies will continue as long as
they must– Future quality measurement will build on silo quality measurement
• Indirect -- Improve medical care delivery and improve health outcomes through:– Development of new care delivery systems. E.g. bundling, accountable
care organizations etc.– Integration – Co-coordination– Co-operation
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The A Team!• Peter Gruhn
-- RUG-IV: Selected Issues and Opportunities• Joy Morrow
-- MDS 3.0 and Operational Issues • Pat Newberry
-- Operationalizing MDS 3.0 and RUG-IV• Peter Gruhn
-- What’s Ahead For SNF Reimbursement• Bill Ulrich
-- Critical Current Billing Issues and More• Jill Mendlen
-- The Future!
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RUG-IV:Selected Issues and Opportunities
Peter GruhnDirector of Research
American Health Care Association
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RUG-IV: Realizing Opportunities
• The New RUG-IV: But Don’t Forget HR-III• RUG-IV: Selected Issues and Opportunities• Operationalizing MDS 3.0 and RUG-IV:
Realizing Opportunities
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The New RUG-IV• Under RUG-IV, CMS will modify the eight levels of the
RUG hierarchy and increase the number of case-mix groups from 53 to 66 in order to better distinguish between relative resource use both within and between RUG groups
• CMS believes that the new RUG-IV system will be more sensitive to differences in patient complexity and the SNF resources needed to provide quality care
• CMS believes that RUG-IV better targets payments to beneficiaries with greater needs– Improved accuracy of Medicare payments– Access to high quality SNF care will be maintained
and enhanced
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The New RUG-IV
• RUG-IV will be implemented in a budget neutral manner
• While budget neutral, RUG-IV will significantly affect the distribution of payments across a significantly regrouped and modified RUG-66 grouper
• However…
…But Don’t Forget About HR-III
• FY 2010 Final Rule:– MDS 3.0 and RUG-IV implementation on Oct 1, 2010
• Patient Protection Affordable Care Act (ACA):– Mandated implementation of MDS 3.0 for FY 2011– 1 year delay in implementation of RUG-IV FY 2012– Implementation of selected RUG-IV elements as
originally set for FY 2011(concurrent therapy and look-back changes)
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RUG-IV versus HR-III
• Issues:– RUG-IV designed to be implemented with MDS
3.0– RUG-III incompatible with MDS 3.0– Need to modify RUG-III and develop grouper to
utilize MDS 3.0 to include RUG-IV elements– Hybrid RUG-III (HR-III) PPS and grouper will not
be ready for implementation on Oct 1, 2010
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RUG-IV versus Hybrid RUG-III
• Response:– CMS plans to apply interim payment rates based on MDS
3.0 and RUG-IV effective Oct 1, 2010 • This way providers can be paid
– Once the necessary infrastructure is in place, CMS will retroactively adjust the rates to reflect HR-III• SNF may need to resubmit claims using HR-III grouper
– HR-III will also be implemented in a budget neutral manner– Legislation is pending in Congress to repeal HR-III, and
proceed with implementation of RUG-IV as specified in last year’s final rule
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RUG-IV: Selected Issues and Opportunities
• RUG-III/RUG-IV: Changes in Distribution• Payment Rate Changes: Issues and Opportunities• Therapy Contracting: Issues to Consider• Assessment Window Pitfalls
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RUG-IV: Issues and Opportunities: Changes in RUG Grouping/Distribution
RUG Category RUG-III RUG-IV HR-IIITotal Rehab 90.2% 82.6% 82.6%Rehab + Extensive 39.0% 4.0% 18.4%Rehabilitation 51.3% 78.6% 64.3%Extensive Services 3.7% 0.9% 5.9%Special Care 2.6% 8.9% 3.9%Clinically Complex 2.7% 4.7% 5.2%Behavioral & Impaired 0.2% 0.5% 0.3%Reduced Physical Function 0.6% 2.4% 2.0%
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RUG-IV: Issues and Opportunities:Changes in RUG Grouping/Distribution
• RUG-III to RUG-IV: Factors– Concurrent therapy adjustment– Pre-admission lookback– ADL scale and scoring– Recategorization– Other (No Section T, SOT OMRAs, Short stay policy)
• RUG-III to HR-III: Factors– Concurrent therapy adjustment– Pre-admission lookback
• Resource: AHCA Medicare RUG-IV Rate Calculator
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RUG-IV: Issues and Opportunities:RUG-IV & (Urban) Payment Rates
RUG-III (FY2010)
RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate % Diff Rate % DiffRUX $617.07 $869.42 40.9% $722.05 17.0%
RUC $528.59 $634.27 20.0% $602.11 13.9%
RVX $467.62 $786.66 68.2% $552.75 18.2%
RVC $421.05 $551.51 31.0% $489.62 16.3%
RHX $395.59 $722.91 82.7% $473.21 19.6%
RHC $364.54 $487.76 33.8% $432.18 18.6%
RMX $448.67 $668.30 49.0% $552.43 23.1%
RMC $335.36 $434.73 29.6% $399.34 19.1%
RLX $318.88 $593.60 86.2% $390.48 22.5%
RLB $294.04 $431.05 46.6% $355.76 21.0%
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RUG-IV: Issues and Opportunities:The Lookback Effect & (Urban) Payment Rates:
The Lookback EffectRUG-III
(FY2010)RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate % Diff Rate % DiffRUX $617.07 $869.42 $722.05
RUC $528.59 $634.27 2.8% $602.11 -2.4%
RVX $467.62 $786.66 $552.75
RVC $421.05 $551.51 17.9% $489.62 4.7%
RHX $395.59 $722.91 $473.21
RHC $364.54 $487.76 23.3% $432.18 9.2%
RMX $448.67 $668.30 $552.43
RMC $335.36 $434.73 -3.1% $399.34 -11.0%
RLX $318.88 $593.60 $390.48
RLB $294.04 $431.05 35.2% $355.76 11.6%
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RUG-IV: Issues and Opportunities:Concurrent Therapy & (Urban) Payment Rates:
RUG-III (FY2010)
RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate % Diff Rate % DiffRUC $528.59 $634.27 20.0% $602.11 13.9%
RVC $421.05 $551.51 31.0% $489.62 16.3%
RHC $364.54 $487.76 33.8% $432.18 18.6%
RMC $335.36 $434.73 29.6% $399.34 19.1%
RLB $294.04 $431.05 46.6% $355.76 21.0%
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RUG-IV: Issues and Opportunities:Concurrent Therapy & (Urban) Payment Rates:
RUG-III (FY2010)
RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate % Diff Rate % DiffRUC $528.59 $634.27 $602.11
RVC $421.05 $551.51 4.3% $489.62 -7.4%
RHC $364.54 $487.76 15.8% $432.18 2.6%
RMC $335.36 $434.73 19.3% $399.34 9.5%
RLB $294.04 $431.05 28.5% $355.76 6.1%
?
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RUG-IV: Issues and Opportunities: The Lookback Effect & (Urban) Payment Rates
RUG-III (FY2010)
RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate % Diff Rate % DiffES3 (SE3) $361.62 $661.20 82.8% $460.76 27.4%
ES2 (SE2) $308.84 $517.58 67.6% $388.17 25.7%
ES1 (SE1) $276.24 $462.34 67.4% $343.98 24.5%
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CE2 $270.03 $361.34 33.8% $336.09 24.5%
CE1 $248.30 $332.93 34.1% $306.10 23.3%
…
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Reimbursement Issues and Opportunities: The Lookback Effect & (Urban) Payment Rates:Extensive Services Qualifier Effect: IV Feeding
RUG-III (FY2010) RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate RateES3 (SE3) $361.62 $460.76
ES2 (SE2) $308.84 $388.17
ES1 (SE1) $276.24 $343.98
HE1 $370.81
HD1 $348.71
HC1 $329.77
HB1 $326.62
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Reimbursement Issues and Opportunities: The Lookback Effect & (Urban) Payment Rates:
Extensive Services Qualifier Effect: IV MedsRUG-III (FY2010) RUG-IV (FY 2011) HR-III (FY2011)
Rate Rate RateES3 (SE3) $361.62 $460.76
ES2 (SE2) $308.84 $388.17
ES1 (SE1) $276.24 $343.98
CE1 $332.93
CD1 $313.99
CC1 $277.69
CB1 $257.18
CA1 $219.30
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Therapy Contracting: Issues To ConsiderNursing
ComponentTherapy
ComponentNon Case Mix Component Overall
RUG-III (FY 2010)RUX $274.76 $263.09 $79.22 $617.07
44.5% 42.6% 12.8% 100.0%RMC $166.10 $90.04 $79.22 $335.36
49.5% 26.8% 23.6% 100.0%
RUG-IV (FY 2011)RUX $566.57 $222.31 $80.54 $869.42
65.2% 25.6% 9.3% 100.0%RMC $288.81 $65.38 $80.54 $434.73
66.4% 15.0% 18.5% 100.0%
HR-III (FY 2011)RUX $374.03 $267.48 $80.54 $722.05
51.8% 37.0% 11.2% 100.0%RMC $227.26 $91.54 $80.54 $399.34
56.9% 22.9% 20.2% 100.0%
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Assessment Window Alert
• Resident Therapy Delivery and the Assessment Window• CMS’s concern:
– MDS does not accurately reflect the services needed by and provided to the resident
• CMS’s guidance:– “Therapy definitions and limitations must be applied
consistently whether or not the resident is in the assessment window”
– “The therapy mode definitions must always be followed and apply regardless of when the therapy is provided in relationship to all assessment windows (i.e. applies whether or not the resident is in a look back period for an MDS assessment)”
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Assessment Window Alert
• Issues:– Possible inconsistency in therapy service delivery
between the MDS and medical record– Invites medical review by MACs, RACs, surveyors– Would there be overpayment recovery and
sanctions?
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MDS 3.0 and Operational Issues
Joy Morrow, RN, PhDSenior Clinical ConsultantHansen, Hunter, & Co., PC
How long it takes to do MDS 3.0
• We believe published information is inaccurate
• From our in the field practice the process is longer
• BUT 3.0 is better• Nurses like the relevance • Residents like it• Families like it• I felt that I really knew the resident
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Residents Must Be Interviewed
• Most residents will be able to be interviewed
• Do not inaccurately presume that resident cannot be interviewed without a professional attempt
• This compliance issue will be surveyed
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Presumption of Coverage
• The original material from Baltimore sounded as if presumption of coverage was gone
• Not true – we still have the presumption with physician order for skilled service that resident is skilled until day 8 of skilled stay or ARD of 5-day assessment whichever occurs first
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Hospital Observation Issues
• Lack of 3 day qualifying stay • SNFs have difficulty discerning observation
vs. inpatient• Elderly are often not ready to be
discharged home and…• They are not eligible for SNF Part A• Hospitals not always forthcoming with
correct information re: observation stays
Most Beneficiaries Who Have Met Qualifying Hospital Stay Criteria
• Meet the criteria for skilled care• Administrative criteria – complexity of non-
skilled conditions…• Safety and stability…• Need for skilled professional nursing care• RUG IV qualifiers • Skilled nursing facility that provides some rehab• “Rehab facility” that rarely provides skilled
nursing
Look Back
• The questions that include look backs longer than admission forward are for information and care planning and overall clinical care
• They are not for reimbursement related to services prior to the SNF admission
• Most look backs are 7 days unless designated otherwise
• The top nine RUG categories will likely have far fewer days
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Extensive Services
• Since admission – trach and vent care• Isolation for active infective respiratory
infection• ADL score 2 or more• Alone or combined with Rehab – not too
likely in most of our facilities
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Setting the ARD
• MDS nurse must know the facility payment rates
• Some nursing categories have better payment than therapy categories
• All patient/residents do not need therapy
• Enhance your skilled clinical nursing services
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Skilled Nursing
• Staff nurses must understand the clinical services that they provide
• Accurate clinically appropriate documentation is a must
• Skilled prompts & check list programs are helpful IF the nurse is using clinical thinking while documenting
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Critical Clinical Thinking
• What services am I providing that require skilled professional knowledge?
• What are the immediate health and safety needs of this patient/resident?
• What are the co-morbidities that I must consider and monitor?
• Does my documentation reflect these professional considerations?
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Default Payment Exceptions
• Remain in effect for allowed circumstances:– Resident discharged during 1st 8 days – Late assessment – default up to ARD
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More Assessments – Quite a Few More
• Some assessments will require sophisticated thinking to ensure appropriate reimbursement
• Combined assessments will need careful thought
• Split RUG assessments
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Start of Therapy (SOT) OMRA
• Optional (even though called “required”)• May be needed to get appropriate
reimbursement• Is used to qualify resident for rehab RUG• MDS will be rejected if the MDS does not
calculate to rehab category
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SOT Details (cont.)
• Facility clinical management needs to manage types of MDSs and communicate with therapy
• The SOT assessment is shorter assessment• Payment starts on first therapy day even
when only one therapy is starting
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End of Therapy OMRA
• Required – establishes non-therapy RUG when therapies are discontinued
• But skilled care continues.• ARD must be set 1-3 days after all therapies
dc’d • Payment is adjusted to non-therapy • Which ARD you pick will NOT affect
payment• Payment changes as of last day of therapy
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Short Stay Policy
• Therapy is pro-rated based on average daily therapy minutes actually provided
• Therapy minutes are divided between the days that treatment minutes were provided
• Treatment minutes must still meet the 15 minutes per day requirement
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Short Stay Policy Includes 8 Requirements for the Start of Therapy MDS
• It requires a competent MDS nurse who considers the RUG categories
• Assesses the payment for each category• Short stay policy may work best for stays
that are only 4 days or less• Latest news from 3.0 facility practice…
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Biggest Decision For CEO/DON
• Do I have the right person in the right job?• Is each MDS nurse competent – exhibiting
critical clinical thinking?• Is he/she willing to embrace the culture change
and really interview and examine each resident?• Is each MDS nurse able to examine and interpret
RUG rates considering resident needs and appropriate reimbursement?
• Does facility need to reassign some roles/tasks?
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CEO/DON Must Understand
• Complexity of 3.0• Transition time needed• Importance of performing job correctly• Correct number of MDS nurses• Difference between Medicare MDSs and
non-Medicare MDSs• Considerations for case-mix states
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Always Have Manual Open
• Use the RAI manual with every MDS• Read the instructions• Read the MDS form instructions• Have a facility policy/guideline that
requires MDS nurses to use the RAI manual
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Concerns
• Since the SOT OMRA is optional, nurses may tend to not do them
• We believe that more often than not this will be detrimental to facility reimbursement
• It is essential that you learn how to combine the SOT OMRAs with the regularly scheduled PPS assessments
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The New Interviews Are Validated
• They are excellent tools • You may need to look at competency of
staff to decide who should perform these specific interviews.
• MSW vs. RN vs. well-trained social worker with B.S. degree, etc.
• Do not rush resident to answer – let them process the question – allow at least 30 seconds
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Changes to ADL Scoring
• Must we verify 3 occurrences?• If so, how should this be done?• Will more effort be required re: ADLs
and documentation?• (Rule of 3 does not apply to bathing)
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ADL Documentation
• ADL flow sheets ???• Computer programs – very good but training
and review are needed• Interviews with direct care givers including
documentation of interview is very good• Daily Part A documentation sheet with limited
important prompts might be a good tool
ADL Assistance does not include:
• Family• Ambulance staff• Wording has changed to state “staff”
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Facility Responsibility Regarding Therapy Services
• Facility must oversee therapy services• That is, make sure that all medical co-
morbidities are being considered…• …that the resident can tolerate the length
and duration of therapy• That individual & other therapy is
performed appropriately• That therapists are timing each individual
residents therapy time• DON often performs this task
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Concurrent Therapy (Sept 2010)
• The therapy mode definitions (individual, concurrent, group), must always be followed and provide regardless of when the therapy is provided in relationship to all assessment windows (i.e. applies whether or not the resident is in a look back period for an MDS assessment
• What does this mean?
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Therapy Aides and Students
• Aides cannot provide skilled services• Only the time an aide spends on set-up
for skilled services may be coded on the MDS (i.e., set up the treatment area for wound therapy) &
• This set up must be directly supervised• Therapy students must have line-of-sight
supervision of the professional therapist
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Determining Therapy Minutes
• Treatment starts when resident begins first treatment activity or task
• Treatment ends when resident finishes with last apparatus or intervention/task
• Count the total minutes including time spent for a therapeutic purpose
• Do not include any other type of break in the total minutes
• Do not round to nearest 5th minute
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Restorative Nursing Program
• The Part A program is underutilized• Appropriate for some at discharge from
hospital• Very good for some who have completed
their more intensive therapy program…• But needs further care to ensure safety &
stability prior to moving to a lower level of care (assisted living, home, etc)
• (Transfers, toileting etc… round the clock)
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Culture Change
• No more one hour comprehensive assessments behind closed doors
• No more 5 minute or “no” minute resident interviews
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The MDS Assessment Is To Be Completed…
• …by face-to-face interview with resident• …by face-to-face interview with staff &
family• …by review of record• An MDS may not be generated after the
resident is discharged (unless sudden death, discharge)
• An MDS may not be generated from only a review of the record
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Care Tool (of the future)
• Standardized assessment across all disciplines
• MDS will no longer be used
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Latest News
• After “press” time
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Life is Change …Growth is Optional
• Sophisticated, educated companies will do alright with regulatory changes
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Operationalizing MDS 3.0 and RUG-IV: Realizing Opportunities
Patricia NewberryExecutive Director of Clinical Reimbursement
UHS – Pruitt Corporation
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
RUG assignment does not mean
skilled care criteria are met
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
RUG IV: 8 Classifications, 66 Groups– Rehabilitation Plus Extensive Services (9)– Rehabilitation (14)– Extensive Services (3)– Special Care High (8)– Special Care Low (8)– Clinically Complex (10)– Behavioral Symptoms and Cognitive Performance (4)– Reduced Physical Function (10)
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
• Key Changes:– Change in Nursing Extensive and Rehab +
Extensive– Hospital Look Back: Eliminated for all
except IV Fluids/Feeding– Therapy Delivery System– ADL Index: Level across each group– Addition of Higher Nursing Acuity
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• Change in Nursing Extensive and Rehab +
Extensive– Ventilator / Respirator– Tracheostomy Care– Isolation for Infection Diseases – per CDC regulation– % of Rehab + Extensive service will drop to < 2%– Rates for these categories have increased
significantly
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• Hospital Look Back: – Eliminated for all except IV Fluids/Feeding
pre admission– All special services can be captured if
provided post admission: in house, ER, MD office
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Operationalizing MDs 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• Therapy Delivery System
– Individual – Group – Concurrent• Impact on RUG level as well as increase in needed
rehab staff and clinical appropriateness of time in Rehab– Example: 50% Concurrent; 25% Group; 25% Individual
• RUG level RUB, 25%+ increase in staff time and resident in rehab in active treatment 5 hours per day at 6 X week
– Example: 60% Individual; 20% Group; 20% Concurrent• RUG level RUB, 10-15% increase in staff time and resident in
rehab in active treatment 3 – 3.5 hours per day at 6X week.
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Operationalizing MDs 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• Assessment Changes– Start of Therapy OMRA– End of Therapy OMRA– Short Stay
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• ADL Index: Level across each group• Impact on Rehab RUGs:– Nursing resources RxA vs RxB.– Recognition of additional nursing resources
needed
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Operationalizing MDS 3.0 and RUG-IV:Realizing Opportunities
Key Changes:• Addition of Higher Nursing Acuity– COPD & SOB while lying flat– DM and insulin orders and insulin injections– Special Care High Categories
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What’s Ahead For SNF Reimbursement
Peter GruhnDirector of Research
American Health Care Association
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SNF PPS: What’s Ahead
• The Market Basket and Productivity Adjustments
• The Market Basket and IPAB• Recalibration (Future budget neutrality
forecast error projection)• Part B Therapy Caps• Non-Therapy Ancillary Services Index• Wage Index• Pay-For-Performance
Market Basket
• Market Basket– Full market basket set in statute– Could only be changed by Congress– But PPACA allows IPAB to change starting in
fiscal year 2015• Market Basket “Forecast Error”– Applied when actual market basket index
and projected market basket index is 0.5% or more different
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PPACA Productivity Adjustment
• 10-year moving average of changes in the annual economy-wide private nonfarm business multi-factor productivity (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost reporting period, or other annual period)
• The most recent data from the Bureau of Labor Statistics would indicate a 1.4% productivity adjustment for skilled nursing facilities.
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Productivity Adjustment• Skilled nursing facilities – fiscal year 2012• Inpatient acute hospitals - 2012• Long-term care hospitals – rate year 2012• Inpatient rehabilitation facilities – fiscal year 2012• Home health agencies - 2015• Psychiatric hospitals – rate year 2012• Hospice care – 2013• Dialysis – 2012• Outpatient hospitals – 2012• Ambulance services – 2011• Ambulatory surgical centers – 2011• Laboratory services – 2011• Certain durable medical equipment – 2011• Prosthetic devices – 2011
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Independent Payment Advisory Board (IPAB)
• Develops and submits detailed proposals to Congress and the President to reduce Medicare spending
• First set of recommendations due in 2014 for 2015 implementation
• HHS Secretary must implement IPAB’s proposals to achieve savings unless Congress adopts alternative proposals with equivalent savings
• IPAB must submit drafts of its proposals to MedPAC and HHS for their review prior to submission to Congress
• IPAB must engage in regular communications with MACPAC.
IPAB’s Reach
• Can recommend payment adjustment only for provider categories not already hit in PPACA with market basket adjustments for the given year
• For example, inpatient hospitals (DRG) already have prescribed market basket hits in addition to productivity adjustments for several years – thus, IPAB has no authority to adjust their rates
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Recalibration• In 2006, CMS refined the SNF PPS CMIs to better
account for resource use of medically complex patients (RUG-53) using 2001 data
• CMS adjusted the nursing weights so that payments under RUG-44 and RUG 53 would be the same
• In the FY2010 SNF PPS NPRM, CMS reported that Medicare expenditures were higher under RUG-53 than they would have been under RUG-44 based on actual 2006 data
• For FY 2010 CMS recalibrated the nursing weights such that payments would be the same
• Payments for FY 2010 were estimated to decline by $1.05 billion (about $16 ppd)
• Recalibration for RUG-III/RUG-IV transition in FY 2013?
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Part B Therapy Caps
• PPACA of 2010 extended therapy caps exceptions process through December 31, 2010
• Cap applies to OT services, and PT and SLP services• CY 2010 cap: $1,860• CY 2011 cap: TBD (Medicare Physician Fee Schedule)• Will the exceptions process be extended?
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Part B: Proposed MPPR Policy
• CY 2011 Medicare Physician Fee Schedule (MPFS) notice of proposed rulemaking (NPRM)proposed to expand the multiple procedure payment reduction policy (MPPR) to Part B therapy services
• CMS proposed to apply a 50 percent payment reduction to the practice expense (PE) component of the second and subsequent therapy services for multiple “always” therapy services furnished to a single patient in a single day
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Part B: Proposed MPPR Policy• Issues and concerns:
– Inadequate notice and regulatory impact analysis (insufficient information on methodology and data were made available in the NPRM)
– CMS analysis flawed• No data from institutional settings was used by CMS
– Underestimation of impact overall and on institutional settings
– Incorrect insights on patterns of service delivery• Duplication analysis flawed (RVU construction issue)• PE and speech therapy• Operational (billing and claim processing issues)
• Substantial advocacy effort by AHCA and other assoc• Stay Tuned: CY 2011 MPFS final rule expected by Nov 1
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Part B: Therapy Cap Alternatives• CY 2011 MPFS NPRM asked for comment on three
potential alternatives to capping therapy services– Option 1: Collect better data on functional status and
severity of patient needs– Option 2: Arbitrary caps coupled with denial of payment– Option 3: New intervention and complexity based
payment system• AHCA submitted comments on the 3 options and
asked CMS to also examine a new episodic-based PPS for Part B therapy services
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Wage Index Reform• Tax Relief and Health Care Act of 2006 (TRHCA)
mandated a revision to the IPPS wage index• MedPAC made recommendations on an
alternative wage index methodology (2007)• CMS contractor Acumen LLC evaluated and
made recommendations on revision/alternative• CMS FY2011 IPPS NPRM requested comments
on Acumen recommendations• CMS will take into account comments as it
evaluates recommendations/next steps• Revised wage index for FY 2012? Stay tuned
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Nursing Home Value Based Purchasing (NHVBP) Demonstration
• 3 year demonstration to test whether a performance-based reimbursement system can:– Improve the quality of nursing home care– Without increasing Medicare expenditures
• Demonstration offers financial incentives to participating nursing facilities that demonstrate:– The ability to provide high quality care and/or– Improve the level of care they provide
• Demo began July 1, 2009• Contactor: Abt and Associates
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NHVBP Demonstration Update
• Demo must be budget neutral• Incentive pool to be created from Medicare
savings achieved through higher quality care• Eligible for incentive payments if have high
performance and/or show significant improvement in the quality of care
• Savings computed at the state level• Incentive payments to be distributed based on the
number of Medicare resident days• If no savings, no incentive payments
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NHVBP Demonstration Update
• Performance Measures– Nurse staffing (level and turnover)– Hospitalization rates– MDS outcomes– Survey deficiencies
NHVBP Demonstration Update• Status: – The Demonstration received approval in
November 2008 and is underway– Data collection phase began in July 2009– Baseline analysis complete– Year 1 data collection complete• 177 participants (38 AZ, 78 NY, 61 WI)• Participation is voluntary
– Evaluation of Year 1 expected Summer 2011– Data collection phase ends June 2012– Final report due June 2013
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NHVBP Demonstration Update
• Section 3006 of the ACA requires the Secretary to develop a plan for a VBP program for SNFs and HHAs
• Plan shall consider:– Selection of quality measures– Reporting, collection and validation of quality data– Structure of payments– Methods of public disclosure
• Report to Congress due October 1, 2011
Critical Current Billing Issues and More
Bill J. UlrichPresident/CEO
Consolidated Billing Services, Inc
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Summary of Current Events
• MDS Transition Billing• PPS and Part A Billing
– 3 – day Qual hospital stay– No pay billing– MACs
• Allow Medicare Bad Debt• SNF ABN• Updated Medicare Cost
Report
• Timely Billing• RAC Audits
– What’s hot
• Therapy Caps• Enrollment 855• Consolidated Billing
– Facility Fee– Under Arrangement
Agreement
MDS Transition Billing
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MDS Transition Billing
• Transition applies to only those residents who have covered Part A days in September and October 2010
• When RUG assignment from one SNF PPS assessment covers days in September and October
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Transition Billing
• RUG-III can be calculated from MDS 2.0 and MDS 3.0
• RUG-IV can’t be calculated from MDS 2.0– Require MDS 3.0 to calculate RUG-IV
• Assessments will be rejected– MDS 2.0 ARD 10/01/10 or later– MDS 3.0 ARD 09/30/10 or earlier
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Transition Billing
• In order to receive payment for covered days in September 2010 must have a RUG-III– MDS 2.0 or MDS 3.0
• In order to receive payment for covered days in October 2010 must have a RUG-IV– Need an MDS 3.0
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Transition Billing - Options
• Options– May opt for default payment under specific
circumstances (in addition to current policy)– May opt to complete MDS 2.0 and MDS 3.0
same type –MDS 2.0 in September and MDS 3.0 early October
– May opt to “substitute” MDS 3.0 for previous type of MDS 3.0
– May opt to “substitute” MDS 3.0 for same type of MDS 2.0
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Transition Billing
• Transition does not apply– When payment ends 09/30/10 or sooner• Medicare stay ends 09/30/10 or sooner• SNF PPS payment for assessment ends 09/30/10
– When payment begins 10/01/10 or later• Medicare care stay begins 10/01/10 or later• SNF PPS payment for assessment begins 10/01/10
Transition Billing
• Transition does not apply–Medicare Start Dates• 07/03/10 => Day 90, 9/30 is last paid day for 60-day• 08/02/10 => Day 60, 9/30 is last paid day for 30-day • 09/01/10 => Day 30, 9/30 is last paid day for 14-day • 09/17/10 => Day 14, 9/30 is last paid day for 5-day
• Must have MDS 2.0 for September payment days and MDS 3.0 for October payment days
Default
• When a resident Part A stay ends 10/01/10 –10/04/10– May opt to not complete applicable PPS
assessment– Required to complete discharge assessment
(OBRA rules apply)– Expectation is that this will be rare event
Billing Transition on UB-04
• Example – option 2– Substitute MDS 3.0 60 day for MDS 30 day
• Continue Rev Code 0022– May need additional row
• Use correct ARD / HIPPS CombinationARD Days HIPPS Comment10/12/10 22 RUC/ 60 days used for 30 day10/12/10 9 RUC/ 60 day MDS
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PPS & Part A Billing Issues3-day stay, No Pays, MACs
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Observation Stay• Three day inpatient stay is limited by observation
days• Observation Stay
– A well defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment and reassessment that are furnished while a decision is being made regarding whether a patient will require further treatment as hospital inpatient.
– Medicare manual provisions suggest than an observation stay should not last more than 24 to 48 hours.
– Beneficiaries are often not aware that observation stays may limit their access to the post acute care benefit.
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Qualifying Hospital Stay
• Do not bill Span code 70 on claims when 3 day transfer criteria is not met
• If Medicare beneficiary dis-enrolls from MA Plans– During SNF Stay
• 3 day stay waived if qualifies for covered service on effective date• Eligible for number of days remaining that would not have been
used
– If after SNF discharge• Must have 3 day stay• 30 day transfer rule does not apply
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No Pay Billing
Medicare Skilled• Submit monthly
covered claim– Benefits exhaust– Remain in certified
bed• CMS = if not in
certified bed, patient should return
Not Medicare Skilled• If patient came in
not skilled– Do not submit claim
• If patient came in skilled– Submit no-pay claim
with discharge status when patient leaves certified bed
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Billing Benefits Exhaust
• Benefits exhaust claim with a drop in level of care within the month– Patient remains in the Medicare-certified area of the facility
after the drop in level of care• Use appropriate bill type 212 or 213
– Bill types 210 or 180 should not be used for benefits exhaust claims submission).
• Occurrence Code 22• Covered Days and Charges = Submit all covered days
and charges as if the beneficiary had days available up until the date active care ended.
• Patient Status Code = 30 (still patient).
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Billing For Denial Notice• Patient previously dropped to non-skilled care. Provider needs
Medicare denial notice for other insurers– Bill Type = 210 (SNF no-payment bill type)
• Statement Covers From and Through Dates – days provider is billing, which may be submitted as
frequently as monthly, in order to receive a denial for other insurer purposes
– No-payment billing shall start the day following the date active care ended.
• Days and Charges = Non-covered days and charges beginning with the day after active care ended
• Occurrence Span Code 74 = include the statement covers period of this claim.
• Condition Code 21 (billing for denial).• Patient Status Code = Use appropriate code.
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Bed Hold PaymentNursing Home
• Pub 100-04• Claims Process
Manual• Trans 1522• CR 6030• Date: 5/30/08• Effect:
6/30/08• Imp: 6/30/08
• Charges to the Beneficiary for admission or readmission are not allowable.
• When temporary leaving the resident can choose to make a bed hold payment.
• What is bed hold payment?– Already been admitted to facility– Has established living space– More than simple agreement to allow re-
admission– Maintain personal effects in a particular
living space.
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Revised Reporting of Assessment Dates [ARD] on UB-04
• Pub 100-04• Claims Process
Manual• Trans 2011• CR 7019• Date: 7/30/10• Effect: 1/1/11• Imp: 1/3/11
• Currently ARD is reported in F.L. 45• Implements new occurrence code 50 for
reporting of ARD• For DOS on or after January 1, 2011• Must include an occurrence code 50 for
each revenue code 0022– Code 50 = ARD– Not required for default HIPPS
• HIPPS must be in the order the beneficiary received that care
Allowable Bad Debt Write-offs
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Medicare Bad Debt
• Allowable bad debt– Dual Eligible – Paid at 100%– Private – Paid at 70%
• Medicare Advantage– Not an allowable Medicare bad debt
• Reasonable Collection Effort• Use of collection agencies• 120 day rule• Must bill policy for Dual Eligible
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Collecting Co-Pay & Deductible
• Provider may bill beneficiary for the following items:– Part A or B deductible– Part A or B co-insurance– Services that are not covered by Medicare
• Provider may request and/or collect:– Part A co-insurance on or after the day in which it applies– Part B deductible or co-insurance on or after the provision
of service to which it applies– SNF may require, request and accept a deposit or other
payment for services if it is clear the services are not covered by Medicare
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Medicare AdvantageCo-insurance
• Most Medicare Advantage plans have a co-pay• Uncollected co-pay is not a Medicare allowable Bad Debt• This leaves Provider at risk of bad debt for Medicaid dual
eligible residents• Recommend
– Re-negotiate with Medicare Advantage– Some plans will pay co-pay if Provider can show Medicaid will not– Send claim to State Medicaid plan
• Once it is denied send claim to Medicare Advantage plan asking for payment
SNF ABN 10055
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SNF ABN – CMS 10055
• Pub 100-04• Claims Process
Manual• Trans 1983• CR 6987• Date: 6/11/10• Effect:
6/11/10• Imp: 7/12/10
• Clarifies the use of Notices of non-coverage and denial letters by skilled nursing facilities.
• SNFs may continue using either the notice of non-coverage or the SNFABN for items and services expected to be denied under Medicare Part A
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Revised SNF ABN
• Use for both Part A and Part B• ABN is not required for care that is excluded by Statue or
fails to meet technical benefit requirement– See voluntary uses
• Mandatory uses– Not reasonable and necessary– Custodial care
• Voluntary– Care that fails to meet the definition of Medicare benefit– Care that is explicitly excluded from coverage under the social
security act• Routine eye care, routine foot care
Medicare Cost Report Updates
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Medicare Cost Report Update
• CMS Transmittal 18• Date 9/8/10• Provider
Reimbursement Manual
• Updates Chapter 35
• Skilled Nursing Facility Complex Cost Report
• A full cost report is required. Simplified method cost report is not allowed after July 1, 1998
• Modification of S-7 to allow New RUG effective October 1, 2010.
• Worksheet B Part III and B-1, Part II are eliminated
• Changes to electronic reporting specifications for CR Ending on or after October 1, 2010
Timely Billing
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Timely Claims Filing
• Pub 100-20• One Time
Notice• Trans 697• CR 6960• Date: 5/7/10• Effect: 1/1/10• Imp: 10/4/10
• Reduces maximum filing timeframe for Medicare claims
• Claims with DOS prior to 10/1/09– Use old rule [due 12/31/10]
• Claims with DOS 10/09 to 12/09– Must be billed by 12/31/10
• Claims with DOS after 1/1/10– Must be billed within 1 calendar year
• One exception 42 CFR 424.44(b)(1)– Error or misrepresentation by
designated official
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Timely Claims Filing
• Pub 100-20• One Time
Notice• Trans 734• CR 7080• Date: 7/30/10• Effect: 1/1/11• Imp: 1/3/11
• Updates CR 6960 to ensure standards are established related to dates of service
• Institutional claims – use claim through date in determining timeliness.
• For physician and suppliers, use the “from” date in determining timelines.
• UB-04 should be based on “through date for both A and B.
RAC Audits
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RAC Audits of Nursing Facilities• Section 302 of the Tax Relief and Health Care Act of 2006 made
the RAC Program permanent and required the Secretary to expand the program to all 50 states by no later than 2010.
• Four Regions– Region A: Diversified Collection Services– Region B: CGI– Region C: Connolly, Inc.– Region D: Health Data Insights, Inc
• Phase-In strategy by Provider Type– RAC audits are not to start until outreach has occurred for that
Provider type in that state.• All Issues review by the RAC must first be approved by CMS and
posted to the RAC website
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What is a RAC?Mission
• The RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments:
• Providers can avoid submitting claims that do not comply with Medicare rules
• CMS can lower its error rate • Taxpayers and future Medicare beneficiaries are
protected
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RAC Audits of Nursing FacilitiesDocument Limits / Self Disclosure
• Additional Document Limits for SNF– 10% of the average monthly Medicare claims (max
200) per 45 days per NPI
• Provider Self Disclosure– If a provider does a self-audit and identifies improper
payments, the provider should report the improper payments to their claim processing contractor.
– If the claim processing contractor agrees that they are improper, the claims will be adjusted and no longer available for RAC review (for that issue).
Type of RAC Reviews
• Automated Review– Black and white issues– No prior contact
• Automated Review Coding Erorrs– NCCI Edits
• Complex Review for Coding Errors– Request Medical Records
• Complex Review for Medical Necessity– Request for Medical Records
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RAC AuditsPrepare for Medical Record Request
• Tell your RAC the precise address and contact person they should use when sending Medical Record Request Letters
• When necessary, check on the status of your medical record (Did the RAC receive it?)
Appeal RAC Finding When Necessary
• The appeal process for RAC denials is the same as the appeal process for Carrier/FI/MAC denials– Do not confuse the “RAC Discussion Period”
with the Appeals process– If you disagree with the RAC determination…
Do not stop with sending a discussion letter– File an appeal before the 120thday after the
Demand letter
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Redetermination [1st level] and Reconsideration [2nd level]
• Limitation on Recoupment extends to the 1stand 2ndlevel appeal ONLY.
• Medicare will not begin recoupment of overpayments (or will cease recoupment that has started) when it receives notice that the provider has requested a redetermination (first level appeal) or a reconsideration second level appeal at the Qualified Independent Contractor(QIC).
• After the QIC determination, Medicare will begin to recoup on any remaining outstanding over payment.
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RAC Review Hot Issues [SNF]
• Region D– Part B – Duplicate payment [Automated]– Ambulance during inpatient stay– Ambulance SNF to SNF transfer– Part B NCCI Edits– SNF Consolidated Billing– Excessive units for untimed codes
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Enrollment 855
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Enrollment Revalidation
• Pub 100-20• One Time
Notice• Trans 558• CR 6486• Date: 9/14/09• Effect:
10/23/09• Imp: 10/23/09
• CMS will being limited Provider revalidation
• Focus on top 50 skilled nursing facility billers– By State
SNF Consolidated BillingFacility Fee, Under Arrangement
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Facility Services billed by Ambulatory Surgical Centers
• Pub 100-04• Claims
Processing Manual
• Trans 1911• CR 6702• Date: 2/5/10• Effect: 1/1/08• Imp: 7/6/10
• New edit will prevent separate payment for facility costs billed by ASC for Part A SNF Stays
• Ambulatory surgeries performed at an outpatient hospital are excluded from SNF CB
• This exclusion does not apply to facility services provided by freestanding ASC– New edit assures that CMS bundles
these services back to the SNF.
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Physician Office Visit• When the physician visits patient in the hospital• Hospital is billing SNF for a room charge, technical
component of 99214 (rev code 510)• 99214 does not have a technical / professional
component designation• SNF help files indicates this is not a bundled code• At least one FI is indicating that the code is bundled
back to the SNF• CMS is in the process of reviewing the issue• Recommendation – Don’t pay the code
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Health Care Reformand the Future of SNFs
Jill MendlenPresident and CEO
Family Choice of New YorkLightBridge Hospice & Palliative Care
Vice-Chair, Finance Committee, AHCA
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CMS Launches a New Approach to Health Care
Triple Aim
Population Health
Per Capita Cost
Experience of Care
Prevention -Reduction of medical errors/ patient safetyBased on best science available
Integrated Care-Journeys not FragmentsPatient centered
Cost Reduction-Specifically NOT by withholding or reducing care
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Change is Underway• Managed Care• Center for Medicare and Medicaid Innovations:– Bundling Payment Pilot- 2013– ACOs – 2012– Pay for Performance (Value Based Purchasing)-2011
• Demos Began 2009
– 20 Payment and Delivery Models for Innovation– Medical Homes -2010
• Federal Coordinated Health Care Office
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Current System Payment and Delivery Silos
MedicareMedicaid
Inpatient Rehab SNF Home Health
Physicians
Managed Care
Long Term Hospital
InpatientHospital
139
Future Payment and Care Management Models
MedicareMedicaid
Bundled Payors
Managed Care
ACOs
Medical HomesDual Care Models
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Complex Universe for SNFs
ACO’s
Medical Home
Hospitals
Bundled Payers
Managed Care
SNF
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Managed Care
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Implications for Managed Care Plans• Government payments to managed care plans
moving toward parity with fee-for-service Medicare
• Increased regulatory and compliance scrutiny• Plans may choose to make up any losses from
payment cuts by increasing premiums or cost-sharing or reducing negotiated rates with providers
• SNP contracts with states will expand Medicaid managed care
• Increased focus on transitions, quality outcomes, and beneficiary satisfaction
• 36 million baby boomers will become Medicare beneficiaries in the next 10 years
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Bundling
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Theory of Bundling• Combining payments, ordinarily paid to multiple
providers to treat a given patient, into a single, “bundled” payment
• Providing providers with an incentive to cooperate with one another and coordinate care throughout the entire episode of a patient’s illness
• The theory -- Providers who have shared financial incentives via bundling will work together to optimize both the services they provide and their reimbursement
• As with capitation, this creates a significant risk that providers could stint on the care that’s needed in order to maximize their reimbursement
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National Pilot Program on Payment Bundling Section 3023
• The Secretary shall develop a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization
• Implementation not later than January 1, 2013• Duration of pilot – 5 years• Secretary to submit plan for implementation of an
expansion of the pilot program no later than January 1, 2016
• May expand the program after January 1, 2016 if it reduces spending and either does not reduce quality of care or improves quality of care
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Statutory Components That Must Be Addressed
1. Scope of services2. Duration of episode3. Selection of patient assessment instrument4. Method of payment5. Selection of bundler or accountable entity6. Selection of quality and outcome metrics
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Additional Components
1. Patient choice2. Selection of risk or case mix adjustment3. Liability4. Medicare benefit changes, e.g.
copayments, deductibles, 3-day stay
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1. Conditions and Services• Ten conditions to be selected for the pilot program • Services that can be covered:– Acute care inpatient hospitalizations– Physician services delivered inside and outside of
the acute care hospital setting– Outpatient hospital services, including emergency
department visits– Post-acute services including home health,
skilled nursing, inpatient rehabilitation, long term care hospital; and other services that the Secretary determines appropriate
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2. Episode of Care • To start 3 days prior to a qualifying admission
to the hospital • And span the length of the hospital stay and 30
days following the patient discharge• The Secretary may determine that another
time frame is more appropriate for purposes of the pilot
• The Secretary may waive such provisions of Title 18 as may be necessary to carry out the pilot program.
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What Happens After the 30th day?
The Secretary shall establish procedures, in the case where an applicable beneficiary requires continued post acute care services after the last day of the episode of care, under which payment for such services shall be made.
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3. Selection of Patient Assessment Instrument
• The Secretary shall determine which patient assessment instrument (such as the Continuity Assessment Record and Evaluation (CARE) tool) shall be used under the pilot program to evaluate the applicable condition of an applicable beneficiary for purposes of determining the most clinically appropriate site for the provision of post-acute care to the applicable beneficiary.
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4. Method of Payment
• The Secretary shall develop payment methods for the pilot program for entities participating in the pilot program.
• Such payment methods may include bundled payments and bids from entities for episodes of care.
• The Secretary shall make payments to the entity for services covered under this section.
• Appears to be budget neutral, i.e. can’t cost any more than would have w/o pilot
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Method of Payment continued…….
• Shall include payment for the furnishing of applicable services and others such as care coordination, medication reconciliation, discharge planning, transitional care services, and other patient-centered activities as determined appropriate by the Secretary.
• A bundled payment shall be comprehensive, covering the costs of applicable services and be made to the entity which is participating in the pilot program.
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5. Who Holds The Bundle?• Not specifically determined by the legislation• “An entity comprised of providers of services
and suppliers including a hospital, a physician group, a skilled nursing facility and a home health agency may submit an application to the Sectary to provide applicable services.”
• Requirement for entities to participate in the pilot program shall ensure that beneficiaries have an adequate choice of providers
• Separate bundle for continuing care hospitals
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6. Quality Measures• Process, outcome and structure and include:– Functional status improvement.– Reducing rates of avoidable hospital readmissions.– Rates of discharge to the community.– Rates of admission to an emergency room after a
hospitalization.– Incidence of health care acquired infections.– Efficiency measures.– Measures of patient-centeredness of care.– Measures of patient perception of care.
• Secretary would have authority to delete, revise, and add quality measures
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Related CMS Initiatives To Date • CMS is testing the CARE Tool under the Post Acute Care
(PAC) Payment Reform Demonstration to standardize patient assessment information in post acute settings
• CMS is promoting better alignment of financial incentives among providers with the following:– Acute Care Episode (ACE) Demonstration
• CMS is engaged though contractors with extensive research on:– Development of episode groupers – Determination of episode costs – Development of episode pricing
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Accountable Care Organizations“Shared Savings Program”
“ACOs”
Medicare Program Must Be established by January 1, 2012
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PPACA Definition of an ACO
• An organization whose primary care physicians are accountable for coordinating care for at least 5,000 Medicare beneficiaries– Having a hospital or specialist in the ACO
is optional– Patients assigned to ACO using primary
care claims
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ACO Requirements
• Required capabilities:– Distribute bonuses– Define processes to promote evidence-based
medicine– Report on quality and cost measures– Be patient-centered
• The beneficiary can still choose any provider inside or outside of the ACO
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ACO Requirements• Have a formal legal structure to receive and
distribute shared savings • Have a sufficient number of primary care
professionals for the number of assigned beneficiaries (to be 5,000 at a minimum)
• Agree to participate in the program for not less than a 3-year period
• Have sufficient information regarding participating ACO health care professionals to support beneficiary assignment and for the determination of payments for shared savings
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ACO Responsibilities under PPACA• Responsible for high quality and low cost– Cost growth allowance is a fixed amount– Quality targets must also be met, Secretary
has discretion over measures and targets• The ACO must coordinate care. This implies
the ACO:– Is responsible for direct communication
among providers– Has a system for knowing when its patients
are admitted and will be discharged from the local hospital
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Benefits for the ACO• Payments made to ACOs in the same manner
they are made under Part A and Part B • Participating ACOs that meet specified quality
performance standards eligible to receive a share of any savings if the actual per capita expenditures of their assigned Medicare beneficiaries are a sufficient percentage below their specified benchmark amount.
163
How Could ACOs Generate Savings?
• Reduce unnecessary services– Admissions– Readmissions– Other
• Switch to lower priced provider– Lower price sector– Lower price provider within a sector
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Implications for SNFs• ACOs will not be the payment source for SNFs but they will:– Manage the care of patients across the spectrum– Have an impact on the choice of post-acute providers– Work to reduce costs– Monitor Quality
• SNFs must:– Make themselves known to ACOs– Provide top quality care– At a reasonable cost
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The Medical Home
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Definition• A patient-centered medical home refers to
physician practices that improve patient care through the help of health coaches, nurses, dietitians and others, as well as with coordinated electronic health records.
• The practices must focus on patient wellness, chronic disease management, reducing medical complications and improving access to care to prevent visits to the emergency department.
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Essential Functions of a Patient-Centered Medical Home*
• Provide each patient with an ongoing relationship with a personal physician who is trained to provide first-contact, continuous, and comprehensive care.
• Provide care for acute and chronic conditions, preventive services, and end-of-life care, or arrange for other professionals to provide these services.
• Coordinate care across all elements of the health care system, with coordination facilitated by the use of registries and information technology.
• Provide enhanced access to care through systems such as open scheduling, expanded hours, and new options for communication between patients and the practice’s physicians and staff.
* Adapted from the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.
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CMS Demonstration• To determine if a medical home could provide better
health care at lower cost to people with Medicare. • A 3-year project required by the Tax Relief and Health
Care Act of 2006, for rural, urban, and underserved areas in up to eight states.
• A board-certified physician will provide comprehensive and coordinated care as the “personal physician” to Medicare beneficiaries with multiple chronic illnesses.
• The doctors selected will receive a care management fee, in addition to the payments for whatever Medicare-covered services they may provide.
• Project to be implemented in 2010.
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Implications for SNFs
• Medical Homes will not be the payment source for SNFs but they will:– Manage the care of patients across the
spectrum– Have an impact on the choice of all providers
• SNFs must:– Make themselves known to Medical Homes– Provide top quality care– At a reasonable cost
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Conclusions• Change will take time but the pace will pick up• SNFs must:– Provide cost, quality outcome and satisfaction data– Sustain and improve quality– Manage costs– Contemplate diversification– Reach out to systems, managed care plans,
bundled payers, ACOs, Medical Homes– Offer value, good patient skilled nursing
management and good transition management
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Questions?
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Contact Information
Elise SmithT: 202-898-6305, Email: [email protected]
Peter GruhnT: 202-898-2819, Email: [email protected]
William HartungT: 202-898-2841, Email: [email protected]
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