Medicare in a Skilled Nursing Facility: Latest News and Trends Judy Wilhide Brandt JudyWilhide.com Par cipants will: Discuss the MDS 3.0 structural changes what is changing and why Familiarize themselves with the update on RUGS and PPS assessment usage per CMS monitoring documents Discuss how "Jimmo vs Sibelius: The Improvement Standard for skilled care may impact SNF level of care requirements. Prospec ve Payment System and Consolidated Billing for Skilled Nursing Facili es (SNF) for FY 2014 1.3% net rate increase $7/Medicare pa ent day CMS con nues to use hospital wage data to adjust the rates for labor costs 128% HIV Add- on remains for diagnosis code 042 (ICD- 10 diagnosis code: B20) SNF Therapy Research Project Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a pa ent during the 7- day look- back period, regardless of the specific pa ent characteris cs. CMS has contracted with Acumen, LLC and the Brookings Ins tu on to iden fy poten al alterna ves to the exis ng methodology used to pay for therapy services under the SNF PPS. No meframe for when a new model will be available Send comments to: SNFTherapyPayments@cms.hhs.gov Rehab Categories Review RU 720 RTM, 5 days 1 discipline & 3 days 2 nd discipline RV 500 RTM, 5 days 1 discipline RH 325 RTM, 5 day 1 discipline RM 150 RTM, 5 days any combina on of disciplines RL 45 RTM, 3 days any combina on of disciplines (+ 2 qualifying restora ve nursing services) SNF Monitoring of FY12 Policy Changes: (Rate recalibra on, group therapy changes, C) No evidence of nega ve impacts Overall case mix has not been affected significantly Providers appear to have adjusted their internal processes and care planning ac vi es well to accommodate policy changes. Therefore, we do not regard the con nued publishing of quarterly memos, in the absence of some marked finding, as s ll being necessary at this point. We will con nue our SNF monitoring efforts but will only post informa on regarding our monitoring ac vi es discussed above to the SNF PPS Web site as appropriate. RTM = Reimbursable therapy minutes 1
SNF Monitoring of FY12 Policy Changes: (Rate recalibra on, group therapy changes, C) Monitoring: CMS Conclusions: Therapy reimbursement for each RUG is based on average u liza on between thresholds Most MDS assessments show that therapy minutes cluster at the minimum threshold For the majority of billed therapy days, the provider is being reimbursed for greater resource intensity than delivered. Oct 2011 thru Final Rule Full Year Dec 2012 2011 2011 2012 RU 45.1% 44.8% 48.6% RV 27.6% 26.9% 25.6% RH 11.1% 10.8% 10.1% RM 7.7% 7.6% 6.2% RL 0.1% 0.1% 0.1% 91.7% 90.4% 90.6% Monitoring: Prospec ve Payment System and Consolidated Billing for Skilled Nursing Facili es (SNF) for FY 2014 Qualifying condi on for Rehab Medium and Low is changing: Old criteria: Rehab Medium: 150 RTM* and at least 5 days of any combina on of disciplines Rehab Low: 45 RTM and at least 3 days of any combina on of disciplines (+ 2 qualifying restora ve nursing services) New criteria: Rehab Medium: 150 RTM and five dis nct calendar days of any combina on of disciplines Rehab Low: 45 RTM and three dis nct calendar days of any combina on of disciplines (+ 2 qualifying restora ve nursing services) Example: PT 75 75 75 75 75 75 75 75 75 75 Tot 150 150 150 150 150 750 PT 75 75 75 Sick 75 75 75 75 75 Tot 150 150 150 150 600 RU RM (C) New block on MDS as of Oct 1, 2013 A er Oct 1 st Per CMS: These two Rehab categories have been incorrectly calculated in RUG groupers since incep on of the RUG system. Inten on was always to require dis nct calendar days, but MDS structure did not allow this. PT 75 75 75 Sick 75 75 75 75 75 Tot 150 150 150 150 600 Did not earn a Rehab RUG (only 4 dis nct calendar days of therapy) 2
Skilled rehabilita ve therapy must be required 5 calendar days a week to meet SNF criteria. Therapy that is purposefully spread out over five days without medical necessity is prohibited. Addi onal Proposed MDS Structural Changes for Oct 1st Su Mo Tu We Th Fr Sa ST ST Unless there is a legi mate medical need for scheduling a therapy session each day, the daily basis requirement for SNF coverage would not be met. Sec 30.6, Ch 8, Medicare Benefit Policy Manual Clarifica on April 1, 2013 During En re 7 days MDS 3.0 Nursing Home Comprehensive (NC) Version 1.11.1 Effec ve 10/01/2013 DRAFT CMS MDS 3.0 Technical Specifica ons Website Addi onal Proposed MDS Structural Changes for Oct 1st Medical Review Ini a ves Co- treatment minutes MDS 3.0 Nursing Home Comprehensive (NC) Version 1.11.1 Effec ve 10/01/2013 DRAFT CMS MDS 3.0 Technical Specifica ons Website Increase and Expand Reviews of SNF Claims CMS should instruct its contractors to: conduct more medical reviews of SNF claims. expand the scope of these medical reviews to more closely scru nize the MDS items that SNFs commonly misreport. iden fy SNFs or SNF chains with recurring problems. target these SNFs in their reviews and possibly refer them for further inves ga on, depending upon the nature of the issues. Use Its Fraud Preven on System To Iden fy SNFs That Are Billing for Higher Paying RUGs CMS should use its Fraud Preven on System to iden fy and target SNFs that have a high percentage of claims for ultrahigh therapy and for high levels of assistance with ac vi es of daily living. 3
Monitor Compliance With C & E CMS should instruct its MACs and RACs to closely monitor SNFs u liza on of these assessments through analyses of claims data to iden fy SNFs using them infrequently or not al all, and target those for review. CMS needs to change how it pays for therapy Current method creates incen ves for SNFs to provide and bill for high levels of therapy when these levels may not be needed. CMS is considering: basing payment for therapy RUGs on pa ent need, by using pa ent diagnoses and service needs to predict the appropriate level of therapy. CMS would also predict the appropriate level of therapy but would then reconcile payments a er the services have been provided. Improve the Accuracy of MDS Items CMS should increase its efforts to ensure that SNFs are comple ng the MDS accurately. Instruct surveyors to cite problema c areas: Therapy and ADL scores Instruct the MACs to provide educa on to all SNFs, as well as specific training to selected SNFs, to improve the accuracy of their MDS repor ng. Medicare will pay for skilled services to maintain an individual s condi on. The determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve." Medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual s condi on, or prevent or slow their decline. They are not covered if the same services could be provided by a non- skilled provider. Jimmo applies to: Nursing Homes, Outpa ent Therapy, and Home Health Care Medicare Part A and B, specifically including outpa ent physical therapy, occupa onal therapy and speech therapy, and long term home health care. Medicare Advantage as well as regular Medicare Jimmo is retroac ve back to the date the case was filed, January 18, 2011 Re- interpreta on, not a new law 4
Final hearings were 1/24/2013 CMS will revise BPM and other manuals, guidelines and instruc ons to correct sugges ons that Medicare coverage is dependent on a beneficiary "improving." New policy provisions will be wri en and added to CMS policy sta ng that skilled nursing and therapy services necessary to maintain a person's condi on, arrest or slow deteriora on, can be covered by Medicare. When these changes are complete, CMS will develop and carry out an educa on campaign for all Medicare providers and adjudicators to explain and implement the maintenance standard. CMS has a year from 1/24/13 to comply JudyWilhide.com Ques ons? 5