Recently, CEO Jim Hoey and Sales VP Jae Sparks attended Reimbursement-Con by Zimmet Healthcare. CMS' Patient-Driven Payment Model (PDPM) was a hot topic, with speakers offering strategies for skilled nursing facilities (SNF) to maximize reimbursement.
To fully appreciate these strategies, let's back up to what we know, what we expect, and some wildcards with PDPM.
What We Know
- PDPM was the biggest overhaul in SNF payments in a generation.
- PDPM was supposed to be budget neutral.
- Before the March 2020 public health emergency, experts said PDPM was more generous than CMS intended.
What We Expect
- CMS wants $1.7 billion back, which could mean a 5% recalibration.
- Using average daily rates in a post-pandemic world could cause a larger recalibration next year, more like 10-12%.
- CMS did not compensate SNFs for COVID care until April 1, 2020.
- CMS assumed all SNFs were affected by COVID in the same way.
- ACOs and value-based purchasing are forcing shorter lengths of stay with sicker patients.
- Due to transitional care units, hospitals are seeing most of the PDPM benefits.
While legislators seek reform, SNFs must still try to survive in the PDPM world. To this point, speakers discussed the best practices. An overriding theme here was using Interim Payment Assessments (IPAs). Only 3% of SNFs are, and it's to your disadvantage.
- CMS wants IPAs to help SNFs track the status of a patient’s conditions and needs for a higher level of care.
- The purpose of IPAs is to establish a payment rate or billing code for billing Medicare Part A.
- Implement IPAs when a resident condition changes and may last 14 days or more.
- Conduct IPAs as a routine when resident stays hits day 21; a lot can change in three weeks.
- Offer specialty care and therapy, like speech and language.
- Stress the importance of documenting all work, using multiple documenters, where possible.
- Correct coding, correct coding, correct coding; billers may need refresher courses.
- Applaud payers when they do the right things, but never take that as enough.
Technology can help.
- Our primeVIEW and Managed Care MASTER solutions allow you to customize alerts on certain clinical conditions or changes that should trigger staff to conduct an IPA.
- Our primeCLAIMS solution makes coding and editing simple and its backed by a support team experienced in post-acute billing.