IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for Rehabilitation Facilities

Transcription

1 IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for Rehabilitation Facilities Carolyn C. Zollar J.D. AMRPA Darlene D Altorio-Jones, PT, MBA-HCM MediServe

2 Medical Rehab FY 2013 Notice and OPPS NPRM IRF Quality Reporting Carolyn C. Zollar J.D. AMRPA Vice President for Government Relations and Policy Development

3 So You Want To Be Paid? Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS)

4 Today s Agenda Brief IRF PPS Refresher Course FY 2013 Notice Changes IRF QRP Proposed Updates Financial Analysis and Implications

5 Review: IRF-PPS Inclusions and Exclusions Includes: PPS Excluded Rehab Hospitals and Units in US & Territories Capital and Inpatient Operating Costs Excludes: Hospitals and Units in Demo Programs (MD) Costs of Bad Debt, Educational Programs, Blood Clotting Factor Units Physician, PA, NP, Midwife, Qualified Psychologist & Anesthetists Services

6 Review: IRF-PPS Applies to Traditional FFS Medicare Cases Only Physician Billing is Separate - Part B, Physician Fee Schedule (PFS) Incentive is to Have the Patient s Costs Stay Under the Payment Most Often Equated to Length of Stay Management Bad, Bad, Bad Idea and CMS Agrees

7 Review: IRF-PPS Basics Data Collection Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Patient Classification System- Case Mix Groups (CMGs) Per Discharge Payment Adjusted For Facility Characteristics Special Payment Policies, Outlier Policy

8 IRF-PPS Basic Components Step One: Case Mix Groups Intended to Reflect Patient Characteristics and Cost of Service Reflect Acuity of the Patient In Terms of: Comorbidities in 4 Comorbidity Tiers A (none) to B (most complex) Functional Independence/Dependence Total Score Ranges Up to 84 For Motor and Self Care and 35 for Cognition FY 2013 CMGs, Weights-See Table 1, p

9 IRF-PPS Basic Components Impairment Group Codes (Condition) Rehabilitation Impairment Categories (21) Categories Case Mix Group Factors ICD-9-Codes that identify the main clinical condition Groupings of similar IGCs Functional Independence Measure Functional assessment based on 17 functional measures determined upon admission (excludes tub/shower transfers); motor FIM scores tend to drive CMG placement Co-morbidities (4 Tiers) Age A condition secondary to principal diagnosis; Generally represent san increase in cost to serve the patient if the condition is present.

10 IRF PPS Basic Components Step Two: Standard Federal Payment Amount Determined from Historic Basis/2002 Updated Through MB Subject to Statutory Change Case Mix Change Wage, Labor Share Budget Neutrality ACA Amendments MB Productivity P4R

11 IRF PPS Basic Components Step Three: Why Facility Adjusters? To acknowledge variations in costs of care among IRH/Us not captured by the CMG weights Low Income Percentage (LIP) Teaching Rural 18.4%

12 IRF PPS Basic Components Step Four: Special Payment Policies Majority of Cases Get One Payment IRH/Us Receive PIP Short Stay Three Days or Less CMG 5001 Death - CMGs Transfers Sent to Another IRH/U, LTCH, Acute, M+M SNF Before Meeting CMS ALOS Formula T = ((CMG Payment/ CMG ALOS) x LOS + 50 % of Per Diem)

13 Special Payment Policies Interrupted Stays Patient Returns to Same Facility On Day of Discharge or By Midnight of Third Consecutive Day Stated Very Curiously Re: Payment (42 C.F.R (g))

14 IRF PPS Basic Components Step Five: Outliers O = 0.80 X ((Cost-Outlier Threshold + CMG Payment)) NTE 3% of Total IRF Payments FY 2013 Threshold - $10,466 from $10,713 FY 2012

15 Late Transmission Penalty Penalty Assessed If Actual IRF PAI Assessment Data Transmission Date > 10 Days from Transmission Date IRF Has 27 Days From (and including) Day of Discharge to Transmit 25% Reduction in CMG Payment Some Exceptions See 412 CFR 610, 614; CR 3885, 7/29/2005

16 IRF PPS Payment Formula P = 1. (Standard Federal Payment Amount) x (CMG Weight 1 ) x 2. Labor Share = Labor Portion of Federal Payment x 3. (Wage Index) = Wage Adjusted Amount + Non Labor Amount 2 = 4. Wage Adjusted Federal Payment x 5. Rural Adjustment 3 x LIP Adjustment 4 = Wage, Rural, LIP Adjusted/FPP 1. Calculated from age, motor and cognitive function and comorbidities 2. Non labor amount = Unadjusted Federal Prospective Payment Labor 3. (1.184) Portion of Federal Payment 4. (1 = DHS ^ (0.4613) 5. (T = FTE/ADC)^(06876))

17 IRF PPS Payment Formula P = 6. Wage and Rural Adjusted Payment Only + 7. Teaching Status Adjustment 5 x = 8. Teaching Status Adjustment Amount 6 = 9. Teaching Status Adjustment + Wage, Rural, LIP Adjusted Rate = Total Payment 10. Outlier (0.80 x (Cost Outlier Threshold + CMG Payment) 5. (T = FTE/ADC)^(06876)) 6. Can be + or -

18 FY 2013 Final IRF PPS Notice: Snapshot Payment Rate for FY $14,343 from $14, 076 Effective for Discharges On or After October 1, 2012 Labor Share is Down from (FY 2008 Market Basket) Average Est. Weight Per Discharge FY to FY No Change in Facility Adjusters Exponential Values or Percentage (Rural) Appendix C List of Comorbidities Unchanged from 8/20/11 List 1 FY 2013 Rate Adjustment File

19 FY 2013 Final IRF PPS Notice: Snapshot Outlier Threshold is $10,466 Down from $10,713 Average Wage Index FY 2013 is v , FY % of IRF Cases in CMGs Where Weights Changed by Less than 5% 0.5% Increased by 15%+ 3.0% Decreased between 5%-15% Largest Increase in Weights Affecting Most Cases Is CMG 0802 No Comorbidity CMS Says Reflects Response to 60% Rule Largest Decrease in CMG Weight Affecting Most Cases 2.3% is CMG D Misc

20 Standard Payment Amounts Year Payment Rate Percentage Change FY 2004 $12, % FY 2005 $12, % FY 2006 $12, % FY 2007 $12, % FY 2008 $13, % FY 2008 Adjusted $13, % FY 2009 $12, % Final FY 2010 $13, % Adjusted FY 2010 per PPACA $13, FY 2011 $13, % FY 2012 $ 14, % FY 2013 $14,

21 FY 2012 and FY 2013 Statistics from CMS FY 2012 FY 2013 Average Wage Index Number of Rural Hospitals Number of Teaching Programs Average DSH Average Est. Weight per Discharge Average IRF Payment with Outlier $5,881,760 1 $5,993,666 1 From FY 2013 Rate File Source: CMS Final Rate Setting Files, Post Correction FY 2012, FY 2013

22 Pay for Reporting: Quality Measures for IRH/Us Starting Soon!

23 CMS Says First Months Are For Training

24 CMS s Final Quality Measures for FY 2014 Reporting National Health Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure Collected For All Patients Without Regard to Payer Percent of Residents Who Have New or Worsened Pressure Ulcers NQF# 0678 Using Data from Pressure Ulcer, Section M, MDS 3.0 CMS Revised the IRF PAI Medicare FFS and Medicare Advantage Patients Data Collected from 10/1/2012 to 12/31/2012 Information on Data Submission Posted 1/31/2012 CMS Holding Training Sessions Open Door Forums

25 Outpatient Prospective Payment System Proposed Rule: IRF QRP Proposals Address When and How a Measure May Be Amended, Retired NPRM Will Be Issued Unless The Data Collection Process Reveals a Safety Issue Addresses When NQF Changes a Measure How CMS Will Determine Whether to Issue NPRM or Sub Regulatory Guidance Like a Transmittal Determinant: Does The Change Substantially Change the Nature of the Measure

26 Outpatient Prospective Payment System Proposed Rule: IRF QRP Proposals Pressure Ulcer Measure Potential Changes Expand to Include IRH/Us and Others Add Patients to Title of Data Collection List CAUTI Changes Change Title to the Above Change Calculation Eventually to Standardized Infection Ratio (SIR) Requires At Least 12 Months of Data Collection List

27 CONTACT INFORMATION Carolyn C. Zollar J.D. V.P. for Government Relations & Policy Development American Medical Rehabilitation Providers Association 1710 N Street N.W. Washington, D. C Toll-free: Phone: Fax: czollar@amrpa.org

28 APPENDIX

29 IRF Regulations Regulation No. Title Year CMS-1433-N Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year CMS-1349-P Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units 2012 CMS-1349-CN Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units; Correction 2012 CMS-1349-F Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units 2012 Website:

30 IRF Regulations Regulation No. Title Year CMS-1344-N Prospective Payment System for Inpatient Rehabilitation Facilities for FY CMS 1538-P Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2010; Proposed Rule 2010 CMS-1538-CN Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2010; Correction 2010 CMS-1538-F Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year CMS-1554-CN IRF PPS for Fiscal Year 2009; Correction Notice 2009 CMS-1554-F IRF PPS for Fiscal Year 2009; Final Rule 2009 CMS-1554-P IRF PPS for Fiscal Year 2009; Proposed Rule 2009 CMS-1551-F Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2008; Final Rule (72 FR 44283) 2008 CMS-1551-P Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2008; Proposed Rule (72 FR 26230) 2008

31 IRF Regulations Regulation No. Title Year CMS-1540-F CMS-1540-CN CMS-1290-F CMS-1290-CN CMS-1480-N Inpatient Rehabilitation Facility Prospective Payment System for Federal FY 2007; Provisions Concerning Competitive Acquisition for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Accreditation of DMEPOS Suppliers; Final Rule (71 FR 48354) 2007 Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2007; Certain Provisions Concerning Competitive Acquisition for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Accreditation of DMEPOS Suppliers; Correction (71 FR 57447) 2007 Inpatient Rehabilitation Facility Prospective Payment System for FY 2006; Final Rule (70 FR 47880) 2006 Inpatient Rehabilitation Facility Prospective Payment System for FY 2006; Correction (70 FR 57166) 2006 Inpatient Rehabilitation Facility Compliance Criteria; Notice (70 FR 36640) 2005

32 IRF Regulations Regulation No. Title Year CMS-1360-CN Inpatient Rehabilitation Facility Prospective Payment System for FY 2005; Correction Notice (69 FR 60157) 2005 CMS-1360-N Inpatient Rehabilitation Facility Prospective Payment System for Fiscal Year 2005 (69 FR 45721) 2005 CMS-1474-P Inpatient Rehabilitation Facility Prospective Payment System for FY 2004; Proposed Rule (68 FR 26786) 2004 CMS-1262-P Changes to the Criteria for Being Classified as an Inpatient Rehabilitation Facility; Proposed Rule (68 FR 53266) 2004 CMS-1262-F Changes to the Criteria for Being Classified as an Inpatient Rehabilitation Facility; Final Rule (69 FR 25752) 2004 CMS-1205-N Inpatient Rehabilitation Facility Prospective Payment System for FY 2003; Notice (67 FR 49928) 2003 CMS-1069-P Prospective Payment System for Inpatient Rehabilitation Facilities; Proposed Rule (65 FR 66304) 2002 CMS-1069-F Prospective Payment System for Inpatient Rehabilitation Facilities; Final Rule (66 FR 41316) 2002 CMS-1069-F2 Prospective Payment System for Inpatient Rehabilitation Facilities; Correcting Amendment (67 FR 44073) 2002

33 IRF Program Transmittals File Date Title Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessment Systematic Validation of Payment Group Codes for Prospective Payment Systems(PPS) Based on Patient Assessments /26/ /13/ /17/2011 Inpatient Rehabilitation Facility (IRF) No-Pay Billing for Medicare Advantage (MA) Patients Update Inpatient Rehabilitation Facility (IRF) and Inpatient Psychiatric Facility (IPF) Cost-to- Charge Ratios (CCRs) Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2012 Revision to Formula to Compute the Time Value of Money under the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Inpatient Rehabilitation Facility (IRF PPS), Inpatient Psychiatric Facility (IPF PPS) and Long Term Care Hospital (LTCH PPS) Website:

34 IRF Program Transmittals File Date Title /13/ /21/2011 Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span Codes (OSCs): Final Completion Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span Codes (OSCs): Phase III /15/2010 Coverage of Inpatient Rehabilitation Services Revised Instructions for Reporting Assessment Dates under the Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF), and Swing Bed (SB) Prospective Payment Systems (PPS) /30/ /15/2010 Coverage of Inpatient Rehabilitation Services /30/ /15/2010 Revised Instructions for Reporting Assessment Dates under the Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF), and Swing Bed (SB) Prospective Payment Systems (PPS) Updates to the Inpatient Prospective Payment System (IPPS), Long Term Care Hospital (LTCH) PPS, Outpatient Prospective Payment System (OPPS), and Inpatient Rehabilitation Facility (IRF) PPS Changes due to the Affordable Care Act (ACA)

35 IRF Program Transmittals File Date Subject /15/2010 Updates to the Inpatient Prospective Payment System (IPPS), Long Term Care Hospital (LTCH) PPS, Outpatient Prospective Payment System (OPPS), and Inpatient Rehabilitation Facility (IRF) PPS Changes due to the Affordable Care Act (ACA) /13/2010 Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY /13/2010 Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span Codes (OSCs) Processing Claims Spanning More than Ten Years with Unlimited /28/2010 Occurrences Span Codes (OSCs): Phase II /12/2010 Update to the Frequency Billing Requirements /3/2010 Outlier Reconciliation and other Outlier Manual Updates for the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Inpatient Rehabilitation Facility (IRF) PPS, Inpatient Psychiatric Facility (IPF) PPS and Long Term Care Hospital (LTCH) PPS

36 IRF Program Transmittals File Date Subject /28/2009 Inpatient Rehabilitation Facility Annual Update: Prospective Payment system Pricer Changes for FY /14/2008 April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Pricer Changes /14/2008 April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Pricer Changes /25/2008 Clarification on the Correct Condition Code to Report on Provider Adjustment Requests to Indicate a Health Insurance Prospective Payment System (HIPPS) Code Change /5/2008 Inpatient Rehabilitation Facility Annual Update: Prospective Payment System Pricer Changes for FY 2009

37 IRF Program Transmittals File Date Subject /13/2007 IOM Pub , Chapters 3- Provider Inquiries and Chapter 6- Provider Customer Service Program Updates /24/2007 Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY /29/2007 IOM Pub , Chapters 3, Provider Inquiries and Chapter 6 - Provider Customer Service Program Updates /14/2007 The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2006 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCHs) /22/2006 CR Inpatient Rehabilitation Facility (IRF) Teaching Status Adjustment 938 5/5/2006 CR Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) 619 1/3/2006 CR Late IRF-PAI Data Submission Penalty Protocol Within the Inpatient Rehabilitation Facility Prospective Payment System

38 IRF Program Transmittals File Date Subject 478 2/18/2005 CR Clarification of the Verification Process to be Used to Determine if the IRF Meets /16/2005 CR Inpatient Rehabilitation Facility Annual Update: PPS Pricer Changes for FY /18/2004 CR Expansion of Policy Where Patient is a Member of a Medicare Advantage (MA) Organization For Only a Portion of the Billing Period to Include Inpatient Rehabilitation Facilities (IRF) and Long Term Care Hospitals (LTCH) 221 6/25/2004 CR Medicare IRF Classification Requirements 263 7/30/2004 CR Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY /29/2004 CR Inpatient Rehabilitation Facility (IRF) Classification Requirements /10/2004 CR The Supplemental Security Income (SSI) Medicare Beneficiary Data for Fiscal Year 2003 for Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)

39 IRF Program Transmittals File Date Subject CR Updated data for determining additional payment amounts for the low-income patient adjustment applicable for 39 12/8/2003 facilities subject to the IRF PPS A /14/2001 CR Instructions for Implementing the IRF PPS: Revision and Modification of Transmittal A A /1/2001 CR Additional instructions for implementing the IRF PPS A /21/2001 CR IRF PPS Revenue Code File Update A /31/2001 CR Instructions for Implementing the IRF PPS CR This PM is informational only. Specific contractor A /30/2000 claims processing instructions will follow A N/A CR IRF Annual Update: Prospective Payment System Pricer Changes for FY 2003

40 Additional Resources Billing Pub 100-4, Chapter 3, Section 140 CMS IRF Home Page / CMG for FY 2013 FY 2013 IRF PPS Notice, July XX, 2012 IRVEN V.2.4 (9/8/10)

41 Items For Your Toolkit IRF PPS Documents Be Familiar With: 1. FY 2002 Final Rule, August 7, 2001 (The Original Payment System) 2. FY 2006 Final Rule, August 12, 2005 (FY 2006 Refinements) 3. Final Rule FY 2007, August 18, 2006 Federal Register 4. Final Rule FY 2007 Correction Notice, September 29, 2006 Federal Register 5. Final Rule for FY 2008, August 7, 2007 Federal Register

42 Items For Your Tool Kit IRF PPS Documents Section 1886 (j) Social Security Act 42 CFR Subpart P, et. seq. New, Revised IRF PAI Training Manual, 2012 Annual SSI, Comorbidity etc., Updates on CMS Website UB Billing Form New Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), 2012 CMS IRF PPS website

43 Items For Your Toolkit IRF PPS Documents cont d Be Familiar With: 6. Final Rule for FY 2009, August 8, 2008 Federal Register 7. Final Rule for FY 2010, August 7, 2009 Federal Register 8. FY 2011 Notice, July 22, 2010 Federal Register 9. Final Rule for FY 2012, August 5, 2011 Federal Register 10. FY 2012 Correction Notice, September 26, 2011 Federal Register 11. FY 2013 Notice, July XX, 2012 Federal Register

44 FY 2006: First Refinements Now 92 Total CMGs, 353 Payment Groups Changed Comorbidities Revised Tier Structure Moved to Weighted Motor FIM Added Teaching Adjustment Adjusted Outlier Policy Took a 1.9 % Reduction for Coding Move To Core Based Statistical Areas (CBSAs)

45 Key Concepts Be Familiar with Rehab Impairment Categories and Impairment Group Codes Be Familiar with Comorbidity Tiers A = None B = Most Severe Tier 1 = Most Severe Tier 3 = Least Severe

46 Key Concepts Be Familiar with ICD-9-CMG Provide Complete Verbal, Written, Dictated Description of Patient On Admission, in H+P and Post Admission Evaluation So Coders Can Properly Assign IGC, RIC, then CMG, Comorbidities and Tiers

47 Facility Adjusters:Low Income Percentage ((1+DSH)^(0.4613)) DSH Patient Percent = (Medicare SSI Days/Total Medicare Days) + (Medicaid, Non-Medicare Days/Total Patient Days) SSI Ratio Important, Published Annually by CMS Used by IRFs to Estimate the LIP Adjustment See CMS IRF PPS Website for SSI Ratio Annual Updates If DSH Phased Out What Happens?

48 TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment Steps 1 Unadjusted Federal Prospective Payment Rural Facility A (Spencer Co., IN) Urban Facility B (Harrison Co., IN) $30, $30, Labor Share X X Labor Portion of Federal Payment 4 CBSA Based Wage Index (shown in the Addendum, Tables 1 and 2) = $21, = $21, X X Wage-Adjusted Amount = $18, = $19, Nonlabor Amount + $9, $9, Wage-Adjusted Federal Payment = $27, = $28,164.41

49 TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment Steps Rural Facility A (Spencer Co., IN) Urban Facility B (Harrison Co., IN) 8 Rural Adjustment X X Wage- and Rural- Adjusted Federal Payment = $32, = $28, LIP Adjustment X X FY 2013 Wage-, Rural- and LIP- Adjusted Federal Prospective Payment Rate 12 FY 2013 Wage- and Rural- Adjusted Federal Prospective Payment = $33, = $30, $32, $28, Teaching Status Adjustment X 0 X

50 TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment Steps 14 Teaching Status Adjustment Amount Rural Facility A (Spencer Co., IN) Urban Facility B (Harrison Co., IN) = $0.00 = $1, FY 2013 Wage-, Rural-, and LIP-Adjusted Federal Prospective Payment Rate 16 Total FY 2013 Adjusted Federal Prospective Payment + $33, $30, = $33, = $31,758.19

51 Facility Adjusters: Teaching Adjustment (( 1+FTE Residents Training in the IRF/ADC)^ (0.6876)) ADC=Average Daily Census Subject to a Cap on the FTE Count FY 2012 Rule Provides Temporary Cap Adjustment Due To IRH/U Closure or Residency Program Closure

52 Payment Example Medical Record Shows CVA Left Sided Hemi Paresis Renal Dialysis, Prostate Cancer, Severe Malnutrition, Dehydration Weighted Motor FIM 24 Age 78 IRF-PAI Shows Motor FIM 26

53 Payment Example Unadjusted RIC = Stroke Scores = CMG 0109 Comorbidities = V45.11 = Tier 1 Unadjusted Payment = $30, for FY 2013

54 Table 13 Possible Future Measures And Topics For The IRF Quality Reporting Program Overarching Goal: Safety and Prevention VTE Prophylaxis. Patient Immunization for Influenza. Patient Immunization for Pneumonia. Staff Immunization. Overarching Goal: Safety and Healthcare Acquired Conditions HAIs Surgical site infections. Multidrug resistant organism infection.

55 Table 13 Possible Future Measures And Topics For The IRF Quality Reporting Program Overarching Goal: Better, Person Centered-Care: Care Coordination/Care Outcome Functional Change: Change in Motor Score. Change in Cognitive Function: Change in Cognitive Score. Communication. Percent of patients whose individually stated goals were met. Care Transitions Measure 3 (CTM 3). Discharge Outcome/Discharge disposition: Home. Assisted Living. Nursing Home. LTCH. Hospital. Hospice.

56 Table 13 Possible Future Measures And Topics For The IRF Quality Reporting Program Patient Preferences for care, treatment and management of symptoms by healthcare providers. Overarching Goal: Better, Person Centered-Care: Symptom Management Percent of patients on a scheduled pain management regime on admission who report a decrease in pain intensity or frequency. Percent of patients with pain assessment conducted and documented prior to therapy. Percent of patients who self-report moderate to severe pain. Percent of patients with dyspnea improved within one day of assessment.

57 Table 13 Possible Future Measures And Topics For The IRF Quality Reporting Program Overarching Goal: Better, Person Centered-Care: Experience of Care Patient Survey, for example, Hospital Consumer Assessment of Healthcare Providers & Systems. Percent of patients for whom care delivered was consistent with patient stated care preferences. * Consistent with NQF Serious Reportable Events. ** Consistent with Healthcare Acquired Conditions (HAC) Prevalence Measure.

58 IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for Rehabilitation Hospitals and Units Starting October 1, 2012 Darlene L. D Altorio-Jones, PT., MBA HCM Strategist, Rehabilitation Management; MediServe

59 Overall Impact Facility Adjusters HOW MIGHT THIS IMPACT YOU? 59

60 Updates to Budget Neutrality Standard Payment Conversion (formally known as Budget Neutral Conversion Factor) Weighting & LOS factors Standard Base Payment Rate $14,076 to $14,343 Outlier Payment Rate: 2012 payments expected 2.8% to be outlier payments. Estimated 2013 aggregate IRF approximately 3% provides a $10,466 outlier 2013 rate (Compared to $10,713 from the 2012 Correction Notice payment amount.) CMG Weights & ALOS Table Updates Let s Review 60

61 CMG Relative Weights Notice CMG Weights & ALOS Table Relative Weights for 353 CMG s 199 or 56 % of cases weighted more or equal to or 44 % of cases weighted less Affect of Standard $14,343 rate: 272 or 77 % of cases paid more or equal to or 23 % of cases paid less ALOS 51 or 14 % have Greater ALOS Published days 148 or 42 % have Less ALOS Published days 154 or 44 % have no change in the ALOS Published days 61

62 2013 Table Comparison CMG Affects 2013 to % CMG Weighted More or Equal 56% ALOS Affects 2013 to % ALOS Greater ALOS Less ALOS Equal 44% 42% 62

63 Affects By RIC /CMG Breakdown 63

64 Cases - Distributional Change Effect 377,040 Cases in 2012 with distributional effects given the CMG relative weight changes Total estimated aggregate payments to IRFs for FY 2013 will not be affected as a result of the CMG relative weight revisions. However, the revisions will affect the distribution of payments within CMGs per a rule statement. and tiers 64

65 Scoring Accuracy Paramount Timely IRF PAI assessment is critical to confirm appropriate Case Mix Index (CMG) being applied. Validation and completion of functional measurement and admit PAI items guide expectations towards clinical resource needs and utilization. Staff must understand the importance of accurate measurement as it leads to appropriate payment to match the intensity/care cost burden required at the individual patient level. 65

66 Rule Payment Example A0110 Rule Example: 66

67 Snapshot Variances Rural/Urban Using the same Indiana Facilities A & B used in the previous example. How does this translate for other common case types? MediServe offers a free tool that enables you to review facility payment with YOUR facility adjusters. This html link is provided upon request and adjusts payment based on your unique payment criteria. 67

68 How Inpatient Rehab Providers Are Paid Wage Index Disproportionate Share Rural or Urban Teaching Status Outlier Payments Short Stays Expired Patients 68

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70 1,108 Facilities - Facility Adjusters Applied Given 1.28 as an average CMI payment for all facilities, MediServe applied the facility adjustment formulas to each facility (CMS data file) and compared a 2013 to 2012 value for a net change in reimbursement. (Positive vs. Negative effects in dollars) Positive > $1 44% facilities Positive >$500 49% 543 facilities Negative 7% 77 facilities Average Change in Reimbursement - After Facility Level Adjusters Positive > $500 49% Negative Change 7% Positive > $1 44% 70

71 Stroke Base Rate Change 2013 to 2012 Standard Payment Base Rates: ( Note* 3,2,1 None Order) 71

72 2013 to 2012 Standard Rate Change Compare 72

73 2013 to 2012 Standard Rate Change Compare 73

74 Fracture LE Base Rate Change 2013 to 2012 Standard Payment Base Rates: ( Note* 3,2,1 None Order) 74

75 2013 to 2012 Standard Rate Change Compare 75

76 ALOS Variance Snapshots 2013 to 2012 Stroke Fx. LE 76

77 Replacement LE Base Rate Change 2013 to 2012 Standard Payment Base Rates: ( Note* 3,2,1 None Order) 77

78 LE Jt. Replacement Base Rate Change 2013 to

79 Miscellaneous Base Rate Change 2013 to 2012 Standard Payment Base Rates: ( Note* 3,2,1 None Order) 79

80 2013 to 2012 Standard Rate Change Compare 80

81 ALOS Variance Snapshots 2013 to 2012 Replacement LE ALOS Changes Miscellaneous ALOS Changes 81

82 Challenges Without focus and interdisciplinary communication it will be nearly impossible to drive expectations expeditiously. Keep focus on impending barriers and the teams ability to eradicate any that stand in the way of the discharge plan. Focus at this level always meets the individuals needed LOS rather than predetermined averages. Review facility ability to meet discharge expectations against YOUR own outcomes. Are the published ALOS significantly different than yours? Manage to individual patient expectations/abilities. Coverage Criteria (2010 Rules) will not go away! Getting paid and keeping payment requires leadership vigilance. 82

83 Expectations & Reality Keeping Medicare payment is contingent on following the Coverage Criteria specifically as detailed. 83

84 14 Criteria = 145 Clarifications * 84

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86 Monitor & Correct Keep your hard earned cash! Know your numbers and continually audit for coverage criteria compliance. Margins can only be managed well when communication and expectations are clearly defined from front to end in the patients experience. 86

87 Questions?

88 Thank You! MediServe AMRPA *CEU forms provided in follow-up

89 CMS Special Open Door Forum ACA Section 3004: Quality Reporting Program for IRFs August 16, 1-2:30 p.m. Call: Conference ID:

90 MediServe Founded in 1985 ( HQ - Chandler, AZ) Specialists - Knowledge & Experience Acute, IRF & Outpatient Rehab Respiratory Service 300+ Organizations