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.

  • 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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  • SNF QRP Provider Preview Reports for Nursing Home Compare Available (11/18)

    By CMS - November 01, 2018
    Skilled Nursing Facility Provider Preview Reports have been updated and are now available. Providers have until November 30, 2018 to review their performance data on quality measures based on Quarter 2 -2017 to Quarter 1 - 2018 data, prior to the January 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate
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  • Q&A: Does anyone have an effective tracking tool for Quality Measure items?

    By Deborah Kriegh, RN DNS-CT, RAC-CT - October 24, 2018
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  • Consider Hand in Hand for Fed Dementia/Abuse Training Requirements

    By Caralyn Davis - October 16, 2018

    The Centers for Medicare & Medicaid Services (CMS) recently released an updated Hand in Hand Series for Nursing Homes, a training series focused on caring for residents with dementia and on preventing abuse. While CMS isn’t currently offering continuing education units (CEUs) for Hand in Hand, the agency recommends—but does not mandate—that providers use Hand in Hand to fulfill federal requirements for training all nursing home staff about dementia management and resident abuse prevention, said CMS officials at the Oct. 11 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF).


    “Federal law requires that nurse aides complete in-service training on dementia management and resident abuse prevention,” they explained. “Additionally, facilities must now provide dementia management and resident abuse prevention training to all facility staff, contractors, and volunteers.”

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  • PDPM At-a-Glance Tool

    By AANAC - October 09, 2018
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  • CASPER Reporting User’s Guide for MDS Providers UPDATED (10/18)

    By QTSO - October 01, 2018
    Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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  • FY 2019 SNF PPS Final Rule PLUS Correction, Updated Wage Index Tables (10/18)

    By CMS - October 01, 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. 

    Correction Notice SUMMARY: This document corrects technical errors in the final rule that appeared in the August 8, 2018 Federal Register (83 FR 39162) entitled “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program.” DATES: The corrections in this document are effective October 1, 2018 .

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  • July 31/Aug. 1, 2018 SNF QRP Training Q&A Document (9/18)

    By CMS - September 24, 2018

    The question and answer (Q+A) for the July 31/August 1, 2018, Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training is now available.

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  • 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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  • 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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