PBJ is just around the corner. So, what is it and what does it mean for you?

PBJ, or Payroll Based Journal describes what CMS requires you to submit online, effective 3Q 2016 and due 45 days after the quarter ends – that’s November 14.  From there, it will become a routine requirement for all SNF providers. And it comes with a kick in 2017 – a Five Star Rating kick. You are probably familiar with PBJ, but let’s net out the essentials so you can understand and act with some urgency. 

Background: With the passing of “The Improving Medicare Post-Acute Care Transformation Act,” or IMPACT Act, providers must submit “payroll and other verifiable and auditable data” electronically to the Department of Health and Human Services. It’s objective? Improve transparency and reduce potentially fraudulent reporting. You can check out the tedious details on the CMS and Federal Register websites:

• FAQs: Electronic Staffing Data Submission Payroll-Based Journal System
• Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection

The Change: In short, PBJ is the CMS’s latest push to keep providers honest when reporting labor hours and census – and eventually, will critically impact your 5 Star Rating.

• Every quarter, providers must use the online PBJ system provided by CMS to report the hours staff – AND contractors – were paid to perform onsite services for facility residents, excluding paid time off (e.g., vacation, sick leave, etc.).
• The PBJ system will only allow XML file submission – one per facility – and/or manual data entry at this time.
• CMS started collecting staffing and census data through the PBJ system on a voluntary basis beginning on October 1, 2015.
• Submission will be mandatory, effective July 1, 2016. Providers will be required to file both staffing and census data no later than 45 days after the last day of each fiscal quarter (i.e. for the quarter ended September 30, 2016 electronic reporting must be completed no later than 11:59 pm EST on November 14, 2016).

Don’t be lulled by the November 14 3^rd quarter reporting deadline. Collecting this data and preparing it for submission will take time – lots of time (and money) – especially if you are trying to do this manually.

There is a way to make this PBJ requirement easier to swallow. We proactively added a PBJ tab to our primeVIEW business intelligence dashboard to help our clients. New clients can also purchase this component on a stand-alone basis to meet the CMS mandate.

Our PBJ Reporting Platform empowers providers to:

• Integrate cross-facility data from employee and census systems
• Manually enter and append contractor data to existing file
• View/monitor a summary of employee and contractor hours
• Automate mapping of labor codes to CMS codes
• Export one all-inclusive XML file per facility for quarterly upload

With staffing and census playing a key role in the CMS’s Five Star rating and compliance, providers can’t afford to waste critical time building reports and checking data. An already-built solution quite simply frees up your time, so you can focus on proactive performance management.

The first mandatory reporting period, starting July, will be here before you know it. The time to act is now. 

And, if PBJ is the first major step you’ll take to aggregate all of the performance data you need to affect your Five-Star Quality Rating, check out our business intelligence blog. 

Fallback, Fill-in, and Backup. No, that is not the call to retreat in the face of overwhelming odds. Although at times, working in a SNF business office can feel like a wave-upon-wave series of assaults on what would otherwise be a normal, methodical day of blissful productivity. Interruptions, urgent requests from the corporate office, and unanticipated call-ins by other office staff, even scheduled absences can be disruptive. But retreat is not the answer. Substitute is the better option - making sure that others are trained to cover the important aspects of the job.

Fallback – Training back-ups is critical

In preparation for this week’s blog, I interviewed Ms. Kimberly Sturm, primeCLAIMS Senior Project Manager. We discussed what business office managers (BOMs) can and should do in anticipation of those times when a member of the office staff calls in or is on maternity leave or vacation. “Cross-train and refresh is what I have advised administrators and office managers throughout my career as a consultant and regional accounts receivable manager,” advises Kimberly. “This is a particular priority for payroll and billing followed by accounts payable, patient trust reconciliation, and other office functions. It seems that facilities don’t have the time before such an absence takes place, but when it does and deadlines have to be met, training happens and sometimes haphazardly. Unfortunately, it is usually long after uncompleted critical tasks have stacked up.” When Kimberly was a regional A/R manager for a large multi-facility SNF operator, one of her office managers, a 26 year old, had a heart attack and was out for 10 weeks. “I had to do the payroll, because the facility did not have a backup,” she explains.

Fill-in – Identify and prioritize

What are the absolute essential office functions that must be performed every day without exception and who do you train? At a minimum, stay on top of the tasks needed to process claims and payroll. Each facility is different with staff members often wearing more than one hat. Unless specifically dictated by corporate policy, the facility administrator or executive director identifies those who should be cross trained.

Fortunately, with back office automation, such as payroll, billing, and accounts payable, training is much simpler with fewer opportunities for errors. Since automation simplifies many office functions, office managers can train with confidence. For example, with a clearinghouse to process claims automatically, converting revenues to cash is easy to learn and manage every day. How does a clearinghouse help? A clearinghouse can furnish all the tools needed to manage claims, DDE, track ADR status, managed eligibility, automate claims submission, plus manage denials-in one system with one log-in. Even though there is still the need for hands-on entries which requires training, it is much easier with claims automation. (Caution: This brings up an important point: with automation comes security. A key part of security is individual log-in credentials. A word from Kimberly, do NOT share log-in credentials.)

Backup – refreshers

“I recommend that even after you’ve trained your office substitutes, that you regularly conduct refresher sessions,” recommends Kimberly. “They don’t have to be long sessions and BOMs can also relate any system changes. Also, have easy-to-understand instructions with screen shots and brief ‘how-to’s’ handy, especially how to access critical files.”

In our recent blogs, we’ve highlighted how Business Intelligence (BI) can help providers more effectively tell their stories to stakeholders, investors, and referral sources. However, providers have another key audience to whom they could effectively present data-driven demonstrations of value and quality – ACOs. In an article published by Healthcare IT News, the author identifies, among other critical success factors, that ACOs need to align the payment model with value and to develop the data model, IT infrastructure, and tools to support reporting and analytics.

Aligning value with payment models

One of my co-workers likes to use the cliché, “Keep it real. In that spirit, because payment model and value alignment are important to ACOs, providers need to understand ACO requirements and to tie their quality improvement initiatives to that payment model. BI can help providers identify and share the results of these initiatives with ACOs, demonstrating payment model-relevant value and service quality.

Developing the data model, IT infrastructure, and tools to support reporting and analytics

Key to successful ACO participation is a dynamic BI tool, the backbone of which is readily interoperable with other systems. Being able to integrate data from various data sources into one common data warehouse will help open lines of communication and care coordination within the payment model parameters. To the extent that LTC providers, with ambitions to participate as a valued and contributing ACO member, have the infrastructure in place, they will be able to more readily integrate their data into the ACO’s existing platform.  

Let me add our two cents – talking the talk; walking the walk

In marketing, we use the term “buyer persona”, which means that for us to effectively communicate, we need to understand who our targeted audience is, their concerns, their interests, etc., and to tailor our communication and engagement efforts accordingly. Likewise, providers need to understand the ACO stakeholder persona(s) and to craft their interactions with those stakeholders by talking their talk and walking their walk. Addressing their concerns with relevant information goes a long way.

Summary

Within the last couple of years, ACOs have begun to recognize that the inclusion of post-acute care providers can contribute to major cost savings and quality care improvement. LTC providers who have BI and data integration technology in place are better positioned to solicit and participate as viable ACO members. Are you one of them? Is ACO participation on your strategic radar screen? If so, having BI and analytics tools to help you demonstrate value in harmony with ACO payment models will help you to stand out among the crowd of ACO membership “wannabees”.

Periodically, you will read about out-of-court settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed to be medically necessary, do not meet the coverage qualifications, or the medical record indicates they were not provided as ordered.

To take the side of an honest mistake, providers can find themselves inadvertently on the wrong side of the False Claims Act if medical record documentation does not support the following:

• A medically necessary admission to a SNF within 30 days of a covered inpatient hospital stay lasting no less than three days,
• That the resident/patient is receiving services and treatments for the condition or injury treated during the qualifying inpatient hospital stay,
• The physician’s certification and subsequent recertification that the services ordered meet each of the qualifying requirements, and
• The documentation identifies that the physician-ordered services were provided as ordered

Further, in an article written in April 2013, Amy E. McCracken wrote that providers must safeguard that claims filed do not include “worthless services” or “implied false certifications,” the two primary theories for the basis of liability. Worthless services suggests deficient services provided inconsistent with physician orders. Implied false certification infers the violation of Medicare or Medicaid regulations.

What are the potential damages? The False Claims Act provides for three times the actual damages and an $11,000 per-claim fine. This can add up quickly. In a recent McKnight’s article, a large provider agreed to pay $600K to resolve False Claims Act allegations. In this case, the facility in question failed to “provide patient care activities as recorded in the resident medical record of a patient and not providing certain care activities consistent with a physician order for more than a month.”

Also, in the case above, the provider has to “pay for a transition consultant to assist the new operator of the skilled nursing facility for a year. This consultant will help ‘identify risks and opportunities for improvement in providing skilled nursing services to residents at the facility.’”

What must providers do to minimize the risk of falling afoul of the False Claims Act?

1. Confirm that the attending physician certifies and then appropriately recertifies the need for skilled care under the definition of skilled services within the SNF.
2. Make sure the care plan is consistent with physician orders.
3. Follow the care plan.
4. Validate that the clinical documentation supports the services provided consistent with the care plan.
5. Reconcile the clinical notes to make sure all disciplines, for example, nursing and rehabilitation, accurately and collaboratively support the resident’s/patient’s condition absent conflict or inconsistencies.
6. Verify that the charges claimed are consistent with the documented physician-ordered services.
7. Take advantage of the triple check process to confirm consistency of charges on the claim with the medical record, care plan, and physician orders. A mere typo can trip you up.
8. Consider self-reporting. If you discover serious billing problems, voluntarily reporting the violation within 30 days of discovery may reduce and damages and penalties significantly.

Violating the False Claims Act carries with it heavy penalties to your hard-fought-for reputation and your finances. Take appropriate steps to minimize the risks. To do nothing would be cents-less.

As the reimbursement world changes from fee-for-service to pay-for-performance models, demonstrating value is key. To be able to compellingly demonstrate value compliant with payment model expectations, providers need to be able to know how well their facilities are performing today. The technology needed to effectively identify and communicate such value is available through business intelligence (BI). As mentioned in a previous post, BI can also be useful in helping providers share information with stakeholders, investors, and even referrals sources.

Let’s assume you’ve identified a particular hospital which shows considerable potential as a referral source to one of your facilities for patients requiring the kinds of services that facility specializes in. With BI, you can effectively tell your story with data-driven information, easily retrieved and configured for presentation. You can bring demonstrated improvement trends in rehospitalization rates tied to clinical best practices and specific diagnoses. Statistically, you can also show how competently your facility treats in-house as well as community-acquired pressure ulcers, physical restraints, falls/accidents, significant weight loss, medications, infections, etc.

You can confidently share with the hospital’s executives discharge information length-of-stay and admissions/discharges information, Five Star ratings compared to peers, and inspection results, such as fines and deficiencies, and quality measures you can present in chart or graph form with trends and benchmarks to state averages. A further indicator of quality within the context of Five Star ratings is labor. BI gives you the opportunity to compare your staffing to 5-Star, 4-Star, and 3-Star requirements.

If your clinical software enables your clinicians to uniquely identify hospitals, you can specifically demonstrate to your audience how well you serve the patients they have discharged to your facility.

What’s most useful is that BI already generates this information for you automatically. You can export it and reconfigure it to meet your audience’s needs. So, what’s required? A BI tool tailored to your organization’s mission, objectives, and best practices, and the opportunity to share your story, to demonstrate your value to the community and the care continuum you serve.