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.

  • SNF QRP 3Q 2018 Help Desk Q+A Doc Includes 2 GG Coding Q&As (2/19)

    By CMS - February 19, 2019
    A new Question and Answer (Q+A) document is now available from the SNF Quality Reporting Program FAQs webpage. The Q+A document reflects frequently asked questions that were received by the SNF QRP Help Desk during the third quarter (July - September) of 2018. It includes information about the SNF QRP program, as well as two section GG coding questions (related to GG0170N and GG0170O).
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  • 7 Ways the DNS Can Lead the Charge for PDPM

    By Caralyn Davis, Staff Writer - February 12, 2019

    Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”


    That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”


    It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”


    Here are seven key steps a DNS can take to get out in front of PDPM:

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  • SNF QRP Nursing Home Compare Updated W/ 1Q 2018 Data (1/19)

    By CMS - February 01, 2019

    The January 2019 Nursing Home Compare Refresh, including quality measure results based on SNF QRP data submitted to CMS, is now available.

    The updated SNF quality measure results are based on data submitted to CMS between:

    1.     Quarter 2 – 2017 to Quarter 1 – 2018 data

    o   Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (#0674)

    o   Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

    o   Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (#2631)

    2.     Quarter 4 – 2016 to Quarter 3 – 2017 data

    o   Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure

    o   Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

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  • Are You Taking the Right Steps to Build Census?

    By Caralyn Davis, Staff Writer - January 29, 2019

    These days, nursing homes face census pressures on multiple fronts. “Some issues are beyond the control of the director of nursing services (DNS),” says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “For example, when census is low at the hospital and referrals simply aren’t out there or when you have trouble hiring staff because your local labor market is extremely tight, you can’t do much about it.”


    However, no matter what outside forces are at play, a DNS still has the opportunity to maximize census, notes Hill. “On the positive side, it’s not a stand-alone endeavor that just adds one more job to the DNS’s task list. Boosting census requires looking at the total picture, so a lot of what you will do to improve census also will benefit your Quality Measures in the different programs, as well as your survey performance.”


    The following steps can help providers get on the right track.

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  • CASPER Reporting User’s Guide for MDS Providers UPDATED (1/19)

    By QTSO - January 29, 2019
    Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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  • SNF QRP California Wildfire Exceptions Document (1/19)

    By CMS - January 18, 2019

    List of counties granted exceptions from the SNF QRP and the length of those exceptions.

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  • PDPM Prep and Skilled Nursing: Secure Skilled Coverage Starting Day One

    By Caralyn Davis, Staff Writer - January 16, 2019

    When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.


    “The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”

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  • AADNS's Pathway to PDPM Readiness Tool

    By AADNS - January 16, 2019
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  • CMS Warns Against Payment-Driven Therapy Under PDPM

    By Caralyn Davis, Staff Writer - December 18, 2018
    The fundamental reason that the new Patient-Driven Payment Model (PDPM) will replace RUG-IV as the case-mix classification system for traditional Medicare Part A residents under the Skilled Nursing Facility Prospective Payment System (SNF PPS) on Oct. 1, 2019, is that “therapy payments under the SNF PPS are based almost entirely on merely the amount of therapy the patient receives,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording when available, here.
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  • FY 2021 SNF QRP Program Data Collection & Final Submission Deadlines (12/18)

    By CMS - December 18, 2018

    Skilled Nursing Facility Quality Reporting Program Data Collection & Final Submission Deadlines for the FY 2021 SNF QRP


    This table provides the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2021 Skilled Nursing Facility Quality Reporting Program (SNF QRP). The first column displays the measure name, the second column displays the data collection time frame, and the third column displays the final data submission deadlines.

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  • Quick Guide to Readmission Measures

    By AADNS - December 03, 2018
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  • SNF QRP Hurricane Michael Data Submission Exceptions (12/18)

    By CMS - December 03, 2018
    The memo lists specific counties that get the exceptions but also notes that SNFs outside those counties can request exceptions if there are extraordinary circumstances.
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  • Side-by-Side View: The Big Changes From RUG-IV to PDPM

    By AADNS - November 26, 2018
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  • SNF QRP October 2018 Help Desk FAQs (11/18)

    By CMS - November 17, 2018

    Skilled Nursing Facility Quality Reporting Program (SNF QRP) Help Desk Questions and Answers (Q+As) and Quarterly Updates October 2018

    The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) was implemented on October 1, 2016. This document is intended to provide guidance on questions that were received by the SNF QRP Help Desk from April 2018 –June 2018 (Section 1). This document also contains quarterly updates and events from April 2018 –June 2018 (Section 2) as well as upcoming updates for the next quarter, from July 2018 –September 2018 (Section 3). Guidance contained in this document may be time-limited and may be superseded by guidance published by CMS at a later date.

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  • Why Some Bad Results Haunt NHC QMs/Five Star—and What to Do

    By Caralyn Davis - November 05, 2018

    The MDS-based CASPER Quality Measures (QMs) that are posted on Nursing Home Compare, some of which drive the QM domain in the Five-Star Quality Rating System, are a frequent source of headaches for directors of nursing services (DNSs). “Everyone wants Five-Stars in the overall composite rating to attract clients, but adverse events often linger on the CASPER QMs much longer than many DNSs and administrators think they will,” says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.


    DNSs should have a basic idea of how long adverse events will impact the CASPER QMs, but that shouldn’t be the primary concern, suggests Maher. “The QMs will impact the overall Five-Star rating, but they have a lesser impact than the survey/health inspection and staffing domains. You must have Five-Stars in your QM domain to be able to add a star to your overall rating, and even Five-Stars in the QMs won’t help if your health inspection rating is one star and you’ve already added a star via the staffing domain. In addition, you have to have only one star in the QM domain to negatively affect your overall rating.” Note: For more information, see the “Overall Nursing Home Rating (Composite Measure)” section of the Nursing Home Compare Five-Star Quality Rating System Technical Users’ Guide.


    So the CASPER QMs are most important as a tool that DNSs can use to identify opportunities for improvement, stresses Maher. “If you focus on providing person-centered care and improving care, you will get to five stars.”

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