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 PPS Fact Sheet From Medicare Learning Network - Revised (1/20)

    By CMS - February 03, 2020
    The basics of SNF PPS and consolidated billing.
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  • Q&A: Are we responsible for dental appointments (toothache) on our Medicare Part A residents or does the dentist bill the family?

    By Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT - November 26, 2019
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  • Upcoming SPADES: CMS Releases Background Info on How They Were Developed (11/19)

    By CMS - November 12, 2019
    Development and Evaluation of Candidate Standardized Patient Assessment Data Elements: Findings from the National Beta Test – Now Available 

    The Centers for Medicare & Medicaid Services (CMS) contracted with the RAND Corporation to identify and develop standardized patient assessment data elements (SPADEs) for use in the following post-acute care (PAC) patient assessment instruments: the Outcome and Assessment Information Set, used in home health agencies; the Inpatient Rehabilitation Facility Patient Assessment Instrument, used in inpatient rehabilitation facilities; the Long-Term Care Hospital Continuity Assessment Record and Evaluation Data Set, used in long-term care hospitals; and the Minimum Data Set, used in nursing homes and skilled nursing facilities. 

    RAND was tasked with developing and testing data elements within five areas of focus that fall under the clinical categories delineated in the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: (1) cognitive function and mental status; (2) special services, treatments, and interventions; (3) medical conditions and comorbidities; (4) impairments; and (5) other categories. This eight-volume report presents background information and results of the National Beta Test, which assessed a set of data elements within the five categories under the IMPACT Act. 

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  • PDPM At-a-Glance Tool

    By AANAC - August 07, 2019
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  • SNF VBP: SNFRM Technical Report Supplement Update (5/19)

    By CMS - May 29, 2019

    The SNF VBP Program awards incentive payments to SNFs based on their performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510). The SNFRM measures the rate of all-cause, unplanned hospital readmissions for SNF residents within 30 days of discharge from a prior hospital stay. The SNFRM is risk adjusted for stay-level factors including clinical and demographic characteristics. Each SNF receives a SNFRM score for a baseline period and a performance period. 

    CMS has issued a supplement update to the SNFRM Technical Report, as well as a planned readmission algorithm.

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  • SNF VBP Home Page Created(5/19)

    By CMS - May 22, 2019
    CMS has created a new online home for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program with the following sections:

    • Measure
    • Scoring Methodology & Payment Adjustment
    • Confidential Feedback Reporting & Review and Corrections
    • Extraordinary Circumstance Exception
    • Public Reporting of SNF VBP Program Data
    • Resources

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  • FY 2020 and FY 2021 SNF QRP Program Data Collection & Final Submission Deadlines (5/19)

    By CMS - April 23, 2019

    Skilled Nursing Facility Quality Reporting Program Data Collection & Final Submission Deadlines for the FY 2020 and FY 2021 SNF QRP

    These two tables provide the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2021 Skilled Nursing Facility Quality Reporting Program (SNF QRP) and FY 2021 SNF QRP. The first column  in each table 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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    • New Payment Models for Therapy Contracts

      By Mark McDavid, OTR, RAC-CT, CHC - March 27, 2019

      October 1 will be here before we know it. And with that comes Medicare’s new Patient-Driven Payment Model (PDPM) for beneficiaries accessing their SNF Part A benefit. It seems like every day there is a new webinar being advertised to help you understand all of the ins and outs of PDPM. It is definitely a more complex system than the RUG-IV system we operate under currently. As we analyze data collected in our facilities, trying to understand where we stand in a PDPM world, there is one other thing to consider: your therapy contract.

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    • CMS Early Findings Report: Initiative to Reduce Avoidable Hospitalizations in Nursing Facility Residents (3/19)

      By CMS - March 20, 2019

      Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents – Payment Reform (NFI 2) Initiative Year 1 (FY 2017)

      CMS is pleased to share the second annual report of the “Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform.”

      Early findings in the report are preliminary and should not be considered conclusive. Nevertheless, the evaluation found some promising evidence that payment reforms have led to a consistent pattern of improved outcomes in newly-recruited facilities. Facilities that had participated in an earlier phase of the Initiative did not show further improvements beyond what was expected based on the trends established during that phase.

      For both groups, additional years of data and analysis should provide more definitive insight about Initiative effects.

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    • ACO Insights From Trinity Health: A SNF Provider and ACO Executive Q&A

      By Caralyn Davis, Staff Writer - March 13, 2019

      For several years now, the Centers for Medicare & Medicaid Services (CMS) has been working to transform both payment and care delivery in the Medicare program. A key vehicle in the agency’s efforts is the Accountable Care Organization (ACO). 

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    • SNF QRP Provider Threshold Report Finally Lets SNFs Track Data Submission Threshold Compliance (3/19)

      By QTSO - March 03, 2019

      The new Skilled Nursing Facility (SNF) Provider Threshold Report (PTR) is now available. This PTR is a user-requested, on demand report which enables users to obtain the status of their data submission completeness related to the compliance threshold required for the SNF Quality Reporting Program (QRP).

      Currently, Fiscal Year (FY) 2020 and FY2021 are available for user selection for this report to assist providers in reviewing Calendar Year (CY) 2018 and CY2019 data submission. The SNF PTR will display an asterisk (*) for future dates (monthly and quarterly) when a measure is active, but data are not available yet. 

      This report is available in the ‘SNF Quality Reporting Program’ category in the CASPER Reporting application. Please refer to Section 13-SNF Quality Reporting Program in the CASPER Reporting MDS Provider User’s Guide for additional information about this report.

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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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    • 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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    • 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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    • 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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