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 Measure Calculations and Reporting User's Manual Update (9/18)

    By CMS - September 14, 2018

    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 (QM), including quality measure definitions, inclusion and exclusion criteria and measure calculation specifications.

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  • July 31/August 1 SNF QRP Post-Training Materials & Videos (9/18)

    By CMS - September 14, 2018


    Post-training materials (includes answers to knowledge checks) from the July/August 2018 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training held in Baltimore, MD, on July 31 and August 1, 2018, are now available. Some screenshots included in presentations for the Section GG and Section N sessions and the Case Study Coding Sheet were updated to reflect recent changes to the Minimum Data Set (MDS) 3.0 Version 1.16.0, which will become effective October 1, 2018.
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  • SNF VBP Performance Score Report Overview video (8/18)

    By CMS - August 30, 2018
    Skilled Nursing Facility Value-Based Purchasing Performance Score Report Overview: 15-minute video from CMS
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  • FY 2019 SNF PPS Final Rule Posted

    By CMS - July 31, 2018
    Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program

    This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019. This final rule also replaces the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV) model, with a revised case-mix methodology called the Patient-Driven Payment Model (PDPM) beginning on October 1, 2019. The rule finalizes revisions to the regulation text that describes a beneficiary’s SNF “resident” status under the consolidated billing provision and the required content of the SNF level of care certification. The rule also finalizes updates to the SNF Quality Reporting Program (QRP) and the Skilled Nursing Facility ValueBased Purchasing (VBP) Program. 

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  • SNF QRP FY 2020 Fact Sheet (7/18)

    By CMS - July 22, 2018
    The SNF QRP Reporting Requirements for FY2020 Reporting Year Fact Sheet is now available. This Fact Sheet contains information about requirements for the SNF QRP for the FY 2020 program year, which reflects data collected from 1/1/18–12/31/18. 
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  • Q&A: When residents are admitted under Medicare or Managed Care, they sometimes have very expensive medications. How are other facilities managing this situation?

    By AADNS Network - July 10, 2018
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  • IMPACT Act QM Development: Transfer of Medication Profile TEP Report (7/18)

    By CMS - July 09, 2018

    TEP Summary Report Available: Development of Quality Measures for the Transfer of Health Information and Care Preferences Domain - Transfer of Medication Profile

    The technical expert panel (TEP) Meeting 4 summary report for the Development of Measures under the Transfer of Health Information and Care Preferences domain is now available. This report summarizes proceedings from a follow-up cross-setting TEP meeting, which included in-depth discussion and input on the following topics:

    ·         Revisions to the measure concept and measure specifications since the TEP last met

    ·         The draft cross-setting Transfer of Medication Profile measures for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies

    ·         The items used to calculate the quality measure

    ·         Importance and feasibility of Information to be included in the medication profile to meet the measure criteria

    ·         Items collecting routes of transfer of the medication profile

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  • CMS SNF VBP FAQs (7/18)

    By CMS - July 02, 2018

    Topics covered include:

    • What is the Skilled Nursing Facility Value-Based Purchasing Program?
    • What SNFs are included in the SNF VBP Program?
    • What measure is currently being used in the SNF VBP Program?
    • What is the difference between a planned readmission and an unplanned readmission?
    • When does the SNFRM 30-day readmissions period begin and end?
    • Are the measures in the SNF VBP Program the same as the measures in the SNF Quality Reporting Program (QRP) and on the Nursing Home Compare website?
    • How are performance scores calculated?
    • Will SNFs be able to calculate their achievement and improvement points?
    • How are incentive payments determined?
    • How will SNFs be notified of their performance in the Program?
    • What is Phase One of the Review and Corrections process?
    • How can I correct an error in my patient-level data?
    • What is Phase Two of the Review and Corrections process?
    • Where can I find more information or ask questions about the SNF VBP Program?
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  • Proposed SNF Patient-Driven Payment Model (PDPM) for Medicare Part A: Technical Resources UPDATED (6/18)

    By CMS - June 20, 2018

    In May 2017, CMS released an Advanced Notice of Proposed Rulemaking (ANPRM) which outlined a new case-mix model, the Resident Classification System, Version I (RCS-I), that would be used to replace the existing RUG-IV case-mix model, used to classify residents in a covered Part A stay into payment groups under the SNF PPS. Since the ANPRM, we continued our stakeholder engagement efforts to address the concerns and questions raised by commenters with RCS-I. This resulted in significant changes to the RCS-I model, which have prompted us to rename the proposed model discussed in the FY 2019 SNF PPS Notice of Proposed Rulemaking (NPRM) the SNF Patient Driven Payment Model (PDPM). 

    June 2018 Update: A few typographical and usability issues were recently identified by certain stakeholders with SNF PDPM the classification logic (SNF PDPM Classification Walkthrough, Grouper Tool, and NTA Comorbidity Mapping).  In order to address these issues, CMS has posted revised versions of the three files below. Stakeholders should use these revised SNF PDPM files to inform their comments on the proposed rule.
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  • PDPM At-a-Glance Tool

    By AANAC - June 19, 2018
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  • Early August: Look for SNF VBP Annual Performance Scores and Phase 2 Program Review and Corrections (6/18)

    By CMS - June 15, 2018
    Phase Two of the Review and Corrections process will begin when annual performance score reports are made available in the Certification And Survey Provider Enhanced Reports (CASPER) system in early August 2018. Phase Two will allow SNFs 30-days to submit correction requests to their SNF VBP performance score and rank only for the FY 2019 Program year. Over the next several months, CMS aims to provide additional resources and training on the Review and Corrections process and how to submit proper Phase One and Phase Two requests.
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  • SNF QRP Table for Reporting MDS-Based QMs for the FY 2020 SNF QRP APU: Big Changes -- Please Review Carefully 5/18)

    By CMS - May 28, 2018
    Please note that, effective Oct. 1, 2018, all of the risk-adjustment items that did not previously count toward meeting the 80 percent threshold for the SNF QRP (e.g., H0400, K0200A/B) WILL begin to be counted. 

    The SNF QRP Table for Reporting Assessment-Based Measures for the FY 2020 SNF QRP APU is now available for download on the SNF Quality Reporting Program Measures and Technical Information webpage. This table indicates the MDS data elements that are used in determining the APU minimum submission threshold for the FY 2020 SNF QRP determination.

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  • QAPI: Survey Citations Happening Now

    By Amy Stewart, BSN, RN, DNS-MT, QCP-MT, RAC-MT - May 09, 2018

    Since November 28, 2017, there have been nearly 100 citations for QAPI failures, according to the Full Text of Statements of Deficiencies released in March 2018. Almost half of the citations are attributed to F867, QAA Activities.

    So, what are other facilities being cited for, and how can you prepare?

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  • SNF VBP Minimum Eligible Stay Threshold Analysis (5/18)

    By CMS - May 07, 2018
    This memo provides analysis to inform the policy consideration of a minimum eligible stay threshold for the quality measure used in the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program— the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510). Specifically, we estimated the reliability of the measure as calculated for various eligible stay thresholds. We also identified the number of SNFs to which the scoring adjustment proposal would be applied at various thresholds.
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  • CMS Touts SNF Cost Savings Under the New PDPM Payment Model

    By Caralyn Davis, Staff Writer - May 04, 2018

    Skilled nursing facilities should save approximately $2 billion in aggregate reduced administrative costs over the next 10 years ($12,000 and 183 hours in savings per provider annually), said officials with the Centers for Medicare & Medicaid Services (CMS) in a review of key aspects of the Fiscal Year (FY) 2019 SNF PPS Proposed Rule during the May 1 Skilled Nursing Facility/Long-term Care Open Door Forum. This estimate is based on the proposed changes to the skilled nursing facility prospective payment system (SNF PPS) assessment schedule associated with the Patient-Driven Payment Model (PDPM) if it’s implemented as proposed on Oct. 1, 2019.


    “While the current [RUG-IV] system requires substantial paperwork to track the volume of service utilization over time, PDPM eliminates the need of these frequent patient assessments and allows clinicians to focus more time on treating the patient,” noted officials. Note: PDPM is based on the Resident Classification System, Version I, or RCS-I, that CMS presented last year.

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