Billing and Payment Initiatives

Reforms in healthcare financing are changing the way care is reimbursed. Understand the ins and outs of everything from Medicare to Managed Care and stay on top of all of the changes that your facility needs to prepare for in the new era of billing and payment.

  • Read Appendix PP: Here’s a Survey Study Guide

    By Caralyn Davis, Staff Writer - August 09, 2017

    “Quite a bit” of the regulatory requirements for survey won’t change with the Nov. 28, 2017, rollout of Phase 2 of the Reform of Requirements for Long-term Care Facilities (aka Mega-Rule), say officials with the Division of Nursing Homes in the Survey and Certification Group at the Centers for Medicare & Medicaid Services (CMS) during the video Appendix PP: Overview of Revised Interpretive Guidance.

    “Most of the minimum quality standards that were in the regulation remain,” they explain. “There are still strong resident rights, use of the Minimum Data Set to do assessment and care planning based on the residents’ goals and preferences, and the input of the interdisciplinary team. There are still requirements for a medical director, a full-time licensed nurse, and requirements for medication review.”

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  • SNF QRP Effective Oct. 1, 2018: CMS Eases Proposed Reporting Burden

    By Caralyn Davis, Staff Writer - August 02, 2017
    As expected, the Fiscal Year (FY) 2018 Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule, released on July 31, covers some significant SNF PPS payment issues. For example, the Centers for Medicare & Medicaid Services (CMS) not only updated the RUG-IV per-diem payment rates, but also revised and rebased the market basket index by updating the base year from 2010 to 2014, and by adding a new cost category for Installation, Maintenance, and Repair Services. Note: For more information about the payment changes, see this CMS fact sheet.
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  • SNF QRP QMs and MDS Items Finalized in FY 2018 SNF PPS Final Rule (8/17)

    By CMS - August 01, 2017
    Specifications for the quality measures and standardized resident assessment data elements for the SNF QRP as finalized in the FY 2018 SNF PPS Final Rule are now posted. 
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  • FY 2018 SNF PPS Final Rule Posted (8/17)

    By CMS - August 01, 2017

    Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020

    AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

    ACTION: Final rule.

    SUMMARY: This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2018. It also revises and rebases the market basket index by updating the base year from 2010 to 2014, and by adding a new cost category for Installation, Maintenance, and Repair Services. The rule also finalizes revisions to the SNF Quality Reporting Program (QRP), including measure and standardized resident assessment data policies and policies related to public display. In addition, it finalizes policies for the Skilled Nursing Facility Value-Based Purchasing Program that will affect Medicare payment to SNFs beginning in FY 2019. The final rule also clarifies the regulatory requirements for team composition for surveys conducted for investigating a complaint and aligns regulatory provisions for investigation of complaints with the statutory requirements. 

    DATES: These regulations are effective on October 1, 2017

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  • SNF PPS Advance Notice of Proposed Rulemaking: Tools for Understanding (8/17)

    By CMS - July 21, 2017
    1. To aid stakeholders in commenting on the SNF PPS Advance Notice of Proposed Rulemaking, CMS posted a building-by-building impact analysis, which provides the estimated Medicare Part A payment impact of the RCS-I model currently under consideration for each SNF. 

    2.  To assist stakeholders in their review of the RCS-I model, CMS provided a narrative discussion of the resident classification logic used under the RCS-I model discussed in the ANPRM. This file provides a step-by-step walk-through that allows stakeholders to manually determine a resident’s RCS-I classification based on the data from an MDS assessment. 

    3. CMS' contractor drafted a Technical Report, which discusses the research conducted by the contractor on developing an alternative to the existing methodology used to pay for services under the SNF PPS. 

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  • CMS SNF QRP Transmittal Explains Payment Reduction Reconsideration Process (7/17)

    By CMS - July 18, 2017

    Fiscal Year 2018 and After Payments to Skilled Nursing Facilities That Do Not Submit Required Quality Data. SUMMARY OF CHANGES: This is a new Change Request (CR) to pub. 100-22, Medicare Quality Reporting Incentive Programs, Chapter 80, to reflect changes to the payment reduction reconsideration process.

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  • SNF QRP Deadline: MDS 3.0 Submission, Submission Status, and Final Validation Reports Helpful Hints (7/17)

    By QTSO - July 18, 2017
    The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Set (MDS) assessment data for January-March (Q1) of calendar year (CY) 2017 are due with this submission deadline. All data must be submitted no later than 11:59 p.m. Pacific Standard Time on August 15, 2017. This document is an overview for MDS providers of the steps required to submit an MDS 3.0 file, verify its submission status, and obtain a Final Validation report. It is strongly recommended that providers access and review the MDS 3.0 Provider User’s Guide and the CASPER Reporting User’s Manual from the MDS 3.0 Welcome page, which is accessed from your state’s MDS Welcome page.
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  • SNF QRP Help Desk Q&As and Quarterly Updates (7/17)

    By CMS - July 09, 2017

    This 13-page document includes 15 Q&As on topics ranging from the data collection period for claims-based QMs in the SNF QRP to the Part A PPS Discharge assessment, as well as links to additional resources.

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  • CMS Releases New Appendix PP Interpretive Guidance for Multiple Tags

    By Caralyn Davis, Staff Writer - June 30, 2017

    Nov. 28, 2017, marks the implementation of some significant changes in how the Centers for Medicare & Medicaid Services (CMS) expects nursing homes to operate—and in the survey process that state surveyors will use to assess those operations. CMS survey-and-certification memo S&C: 17-36-NH gives providers critical information about how to prepare for these changes that are required under Phase 2 of the roll-out of the Reform of Requirements for Long-term Care Facilities (aka Mega-Rule) updating the Medicare/Medicaid conditions of participation. This information includes an advance copy of 696 pages of revisions to the F-tags and the Interpretive Guidance in Appendix PP, “Guidance to Surveyors of Long-term Care Facilities,” of the State Operations Manual. Providers should note that the Appendix PP revisions include new subregulatory guidance for multiple F-tags, not just the Phase 2 regulatory changes.

    Here’s a summary of critical news—and what’s still to come:

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  • SNF QRP Review and Correct Reports Available (6/17)

    By QTSO - June 19, 2017

    The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Review and Correct reports are now available on demand in the CMS Certification and Survey Provider Enhanced Reporting (CASPER) application. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

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  • SNF QRP Technical Specs Table for Reporting MDS-Based QMs for FY 2017 (6/17)

    By CMS - June 05, 2017
    his table presents information to understand the reporting requirements for the assessment based quality measures that are included in the Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) for FY 2017. This table provides details for each MDS item and assessment type, allowable item values when coding for the 3 assessment based quality measures, Falls with Major Injury, Pressure Ulcers New or Worsened, and Functional Assessment and Care Plan.
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  • May 2 SNF QRP Review & Correct Reports Provider Training Q&As (5/17)

    By CMS - May 26, 2017

    May 2 Review and Correct Reports Provider Training Question and Answer (Q&A) Document for the Skilled Nursing Facility Quality Reporting Program Is Now Available: The question and answer (Q+A) document from the Review and Correct Reports Provider Training is now available in the “Downloads” section below. The Q+A document contains participant questions from the Live Webcast which took place on Tuesday, May 2, 2017.

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  • SNF QRP Review and Correct Reports Provider Training Slides and Video (5/17)

    By CMS - May 26, 2017

    TRAINING MATERIALS AVAILABLE for the May 2 Review and Correct Reports Provider Training – Webcast. The focus of this training is to assist providers from the following care settings in better understanding how Review and Correct Reports fit within the overall Quality Reporting Program: Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Long-Term Care Hospitals. Additionally, this training will provide information about re-submitting data to correct errors prior to the quarterly submission deadlines to ensure the accuracy of the data which will ultimately be publicly displayed.

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  • Final Notice: Meet June 1 SNF QRP Data Submission Deadline or Lose Part A $

    By Caralyn Davis, Staff Writer - May 24, 2017
    Skilled nursing facilities that participate in the skilled nursing facility prospective payment system (SNF PPS) have until 11:59 p.m. Pacific standard time on June 1, 2017, to correct and/or submit their MDS quality data for Oct. 1 – Dec. 31, 2016, to fulfill the requirements for the Skilled Nursing Facility Quality Reporting Program (SNF QRP) fiscal year (FY) 2018 payment determination. Some providers have been confused by the upcoming release of the SNF QRP Review and Correct Reports, thinking those reports would allow them to identify corrections they need to make to meet the 80 percent threshold. However, the Review and Correct reports relate specifically to the calculation of the SNF QRP quality measures (QMs), not to meeting the required data threshold for payment.
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  • SNF QRP Quality Measure (QM) User's Manual - NEW (5/17)

    By CMS - May 23, 2017

    This manual presents methods used to calculate quality measures that are included in the Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). This manual provides detailed information for each quality measure, including quality measure definitions, inclusion and exclusion criteria and measure calculation specifications.

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