Continuing Education Unit Conditions

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1 Georgia State Office of Rural Health & HomeTown Health Best Practices for Compliance & Efficiency Rural Swing Bed Management (RSBM) Training Program Use of Swing Beds in CAH Hospitals: SKILLED ANCILLARY SERVICES This project is supported by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) grant number 16062G. Continuing Education Unit Conditions As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEUs/1 credit hour for this program today. In order to obtain these CEUs, you must: View recording in its entirety within 30 days Pass online quiz with 80% or better. Complete webinar evaluation. RSBM Live Trainings for CAH RURAL SWING BEG MANAGEMENT: FOCUS ON COMPLIANCE North Georgia RSBM Program provided by HomeTown Health Habersham Medical Center, US Hwy 441 Business Demorest, GA August 25, 2017, from 9:00am to 3:00 pm South Georgia State Office of Rural Health, 502 Seventh Street South Cordele, GA August 18, 2017, from 9:00am to 3:00 pm 1

2 Agenda Welcome & Introduction Desi Barrett, Webinar Program Manager CAH Swing Bed Presentation: Skilled Ancillary Services Next Steps Dashboard & Calendar Kerry Dunning RSMB Program Trainer Kerry Dunning, LLC Desi Barrett, Webinar Program Manager RSBM Program Trainer Kerry Dunning LLC Ms. Dunning has 20 years in health care consulting and over 30 years in the industry. She specializes in the post-acute market working with hospital based skilled nursing and swing bed programs, critical access hospitals, freestanding skilled facilities, inpatient/outpatient rehab programs, inner city teaching hospitals and rural health care systems. Ms. Dunning worked for HCA and HealthTrust hospitals in administrative roles; Horizon Rehabilitation and ServiceMaster Rehabilitation as a Sr. Vice President and Chief Operating Officer; with GPS Healthcare as the Chief Senior Services Officer; and has spent more than 20 years as an independent consultant. In addition to serving as an Adjunct Instructor in the College of Health at the University of North Florida, Ms. Dunning regularly leads workshops and webinars regarding Medicare, skilled nursing (including MDS), swing bed programming, and reimbursement cycle improvement. She also works on international health care projects and research. Her favorite job is on-site helping facilities take better care of patients. Kerry Dunning, MHA, MSH, CPAR, RAC-CT Kerry Dunning LLC CAH June

3 Kerry Dunning has no proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The education offered by Kerry Dunning, LLC in this program is compensated by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) under grant number 16062G. Based upon Center for Medicare and Medicaid (CMS) Swing Bed Providers guidelines, Georgia State Office of Rural Health identified needs, and hospital based skilled nursing and swing bed program best practices, participants will be able to: 1. Recall CMS, OIG and MedPAC data regarding ancillary services usage 2. Recognize the required documentation to support ancillary services being provided 3. Understand the importance of physician documentation to support ancillary service usage 4. Comprehend SNF consolidated billing provisions set forth by Medicare for CAH hospitals. 5. Explain how to set up a self-audit of ancillary services, including tracking usage by physicians RCS expected in 18 months 9 3

4 Swing beds must follow skilled nursing guidelines but the rules are not always well defined. CAH swing beds must be vigilant in understanding Medicare intent, documenting to CMS standards, and achieving measurable outcomes Staff need to understand cost and how it is matched to medical necessity 10 Ancillary defines why the complexity is such that the service can only be provided in a SWB BUT Ancillary cost drives the expenses that can cost more than the reimbursement SWING BED GUIDELINES USED TO BE THE ONLY GUIDELINES THE RULES HAVE CHANGED Enrolled in Medicare Part A Medicare Advantage follow Medicare intent but insurance is a separate product Benefit days available to use Applies to Medicare and MC Advantage 3-day qualifying acute inpatient admission Required by Medicare A; others vary from 1 to 3; some headed for no qualifying hx stay Qualifying condition The qualifiers have not changed f Services must be provided for a Important that diagnoses documented condition which was treated during the during stay (including thx treatment qualifying acute inpatient admission; codes) are captured on the claim or Still true for Medicare A but used less Arose while the patient was in the because of reduced LOS swing bed for treatment of another condition for which the patient had been previously treated in a hospital Within 30 days of discharge Requires daily skilled nursing services or skilled rehabilitation which can only be provided in a SNF or Swing Bed Medicare A but insurance has to be pre-certed All payors will consider Home Health or Outpatient services as an alternative to the more expensive inpatient stay 11 CMS Non-therapy services costs comprise about 25% of the daily costs of care for Medicare SNF residents An ALJ determined that Medicare paid for the hospital services under Part B as outpatient and ancillary charges and, therefore, Medicare would not cover the SNF services because the beneficiary did not have a three-day qualifying inpatient hospital stay. OIG According to Medicare reimbursement rules, supplies and services that can be considered ancillary are limited to only those supplies and services that are directly identifiable to an individual patient, furnished at the direction of a physician because of special medical needs, and are either not reusable, represent a cost for each preparation, or are complex medical equipment. MedPAC SNF Therapy Costs, and as a subset how other ancillary services are paid, and is the patient getting all services needed 12 4

5 In 2011, Medicare spent nearly $32 billion on skilled nursing care* Skilled nursing facilities offer: Post-hospital and post-surgical care SNF regulations are the standard for Assistance with activities of daily living any SWB program Incontinence, catheter & colostomy care Individualized care plans Medication administration and IV services Therapeutic and special diets Diabetic management Medical supplies and durable medical equipment during the stay Restorative Rehabilitation services (SNF) PT/OT/Speech-language pathology services Pharmacy Ambulance transportation *Source: Medicare Payment Advisory Commission 13 Ancillary services fall into three broad categories: diagnostic, therapeutic and custodial. If your physician sends you for an x-ray of your injured leg, she is using a diagnostic ancillary service If after repairing the bone in your leg, she sends you to a physical therapist for proper exercise routines, she is using a therapeutic ancillary service Nursing homes providing custodial care are an ancillary service also Non-therapy diagnostic tests and other typically Part B services are provided in the skilled setting 14 CAHs have a 25 bed limit CAH-based swing beds are cost-reimbursed No MDS assessments are required CAH SWBs are exempt from SNF PPS Consolidated Billing provisions BUT The Atlanta Regional Office is now supplying at least one different interpretation of extraordinary cost and not consistent with the scope of services offered at the skilled level of care 15 5

6 Although the Skilled Nursing Facility Prospective Payment System (SNF PPS) bundling rules do not apply to CAHs, the hospital bundling rules apply to CAHs (section 1862(a)(14) of the Social Security Act). Section 1862(a)(14) is implemented in the regulations at Title 42 Section (m) of the Code of Federal Regulations (CFR). The title of 42 CFR is Particular services excluded from coverage. (m) Services to hospital patients (1) Basic rule. Except as provided in paragraph (m)(3) of this section, any service furnished to an inpatient of a hospital or to a hospital outpatient (as defined in of this chapter) during an encounter (as defined in of this chapter) by an entity other than the hospital unless the hospital has an arrangement (as defined in of this chapter) with that entity to furnish that particular service to the hospital's patients. As used in this paragraph (m)(1), the term hospital includes a CAH. (2) Scope of exclusion. Services subject to exclusion from coverage under the provisions of this paragraph (m) include, but are not limited to, clinical laboratory services; pacemakers and other prostheses and prosthetic devices (other than dental) that replace all or part of an internal body organ (for example, intraocular lenses); artificial limbs, knees, and hips; equipment and supplies covered under the prosthetic device benefits; and services incident to a physician service. 16 (3) Exceptions. The following services are not excluded from coverage: (i) Physicians' services that meet the criteria of (a) of this chapter for payment on a reasonable charge or fee schedule basis. (ii) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act, that are furnished after December 31, (iii) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (iv) Certified nurse-midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, (v) Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, (vi) Services of an anesthetist, as defined in of this chapter. CMS reads these regulations to say that if the services are provided under arrangement to the CAH patient, then the CAH bills for the service and would be paid accordingly based on costs. If not, the separate entity would bill for the service. If the ESRD facility is providing dialysis to the CAH swing bed patient under arrangement, the CAH bills for the service. If not, the ESRD facility would bill for the service. Lana Dennis/CMS/Atlanta Regional Office 17 On May 1, you asked about several services provided to a CAH swing bed patient. I offered the initial information below and indicated I would research your inquiry further. Currently, the technical advisor of the Center for Medicare s Chronic Care Policy Group/Division of Institutional Post- Acute Care and the acting director of the Division of Acute Care within the Center for Medicare s Hospital and Ambulatory Policy Group are discussing this. I will provide you additional information as soon as I can. 18 6

7 CAH SWBs are treated as SNF and subject to: SNF Part A coverage, deductible, coinsurance Physician certification/recertification provisions Extended Care services must be provided directly or under arrangement Nursing care provided by or under supervisions of registered professional nurse Room and Board PT, OT, ST Medical Social Services Drugs, biologicals, supplies, appliances and equipment, furnished for use in the SWWB Other services necessary to the health of the patients as are generally provided by SNFs, or by others under arrangement All Services outside the extended care scope will remain on the claim (services will be reimbursed at cost) 19 Emergency services are defined in the regulations at 42 CFR as... services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. In this context, false alarm situations may occasionally arise, in which the initial assessment of a beneficiary s condition as lifethreatening subsequently proves to be unfounded (for example, where a patient s chest pain and shortness of breath initially appear to be symptoms of a heart attack, but upon subsequent examination turn out to be merely a bad case of indigestion). Such situations still qualify for the emergency services exclusion from SNF CB as long as the initial symptoms provided a reasonable basis for assuming the onset of a medical emergency, even though this assumption ultimately was not borne out by subsequent events. 20 Ensuring orders from qualified practitioners with appropriate diagnostic justification (i.e., medically necessary services) is an ongoing challenge for healthcare providers, particularly with diagnostic testing. IF the diagnosis codes are not justified, then the medical necessity for the services may be questioned and overpayments determined. 21 7

8 The two most expensive services paid within the RUG per diem allowed The acuity level of patients in skilled settings continues to rise The number of medications per patient is increasing The demand for and the demand for skilled services is projected to dramatically rise due to the aging population The U.S. Health Care System loses billions of dollars annually manufacturing, distributing, and disposing of unused medications The estimated cost of unused medications for the more than 2.5 million residents in nursing homes is estimated to be more than one billion dollars annually. On average, the average cost of medication waste per resident is over $500 per year. 22 Medications only brought into the skilled nursing facility by patients may be utilized upon a written order from the patient's physician. All medications brought into the skilled nursing facility and utilized by inpatients will be verified by a Pharmacist as the proper medication prior to administration. Only upon a written order from the patient's physician may a patient use his/her home medication. The usual information for a drug order is required (i.e. drug name, strength, dose, directions). For their safety, patients cannot keep any medications at their bedside. 'Patient may take own med' is not considered a valid order and should be revised with the physician. A revised order must be written in the patient's chart. The medications are entered on to the electronic health record with the notation "Home Meds" state that the medication has been identified and the location where the medications will be stored. There is not a charge for administration of these medications OR If your stay in a nursing home is being covered under the Medicare Skilled Nursing Facility (SNF) benefit, your prescription drugs will be covered by Medicare Part A, not by your Medicare private drug plan (Part D). 23 In December 2006, CMS released updated surveyor guidance for unnecessary drugs (greatly expanded from earlier OBRA guidelines), focusing on the resident s entire medication regimen and the components of medication management: 1. Indication 2. Monitoring, dosage 3. Duration 4. Attempts to discontinue or reduce dosage 5. Prevention, identification and response to adverse consequences. 24 8

9 Thus, medications lacking a diagnosis for use can be deemed Unnecessary, causing a denial in payment. SOM Appendix PP/ F-tag 329 states each resident s regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) in excessive dose (including duplicate therapy or (ii) for excessive duration or (iii) without adequate monitoring or (iv) without indications for its use. NOTE: this guidance applies to all categories of medications including antipsychotic medications. 25 Every year there are more tests available for doctors to order. What are the required components of a valid physician order? Physicians should sign all orders for diagnostic services to avoid potential denials. If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. Should include beneficiary name, order date, specific tests ordered, and valid provider signature. What is documentation of intent to order? A progress note or office note to support intent (tests to be performed should be clearly indicated). 26 Following the RAI manual for guidance: make certain that you record all time spent in the patient s room when conducting each treatment. These services can be provided by nursing (competency based) as well as RT Nebulizer and skilled level of care have been questioned 27 9

10 483.25(i) Nutrition Based on a resident s comprehensive assessment, the facility must ensure that a resident (i)(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident s clinical condition demonstrates that this is not possible; and (i)(2) Receives a therapeutic diet when there is a nutritional problem. 28 INTENT: (i) Nutritional Status The intent of this requirement is that the resident maintains, to the extent possible, acceptable parameters of nutritional status and that the facility: Provides nutritional care and services to each resident, consistent with the resident s comprehensive assessment; Recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition; and Provides a therapeutic diet that takes into account the resident s clinical condition, and preferences, when there is a nutritional indication. 29 Although the Resident Assessment Instrument (RAI) is the only assessment tool specifically required, a more in-depth nutritional assessment may be needed to identify the nature and causes of impaired nutrition and nutrition-related risks. The assessment will identify usual body weight, a history of reduced appetite or progressive weight loss or gain prior to admission, medical conditions such as a cerebrovascular accident, and events such as recent surgery, which may have affected a resident s nutritional status and risks. What are the appropriate diagnoses needed? 30 10

11 Consistent with the symptoms or diagnoses of the illness or injury under treatment Necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational) Not furnished primarily for the convenience of the patient, the attending physician, or the family Furnished at the most appropriate level that can be provided safely and effectively to the patient 31 COMPREHENSIVE ASSESSMENT The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident s functional capacity. COMPREHENSIVE CARE PLAN An OIG report found that SNFs did not meet quality-of-care requirements. 37 percent of SNF stays in 2009, either the plan did not meet Medicare requirements or the care was not administered according to the plan. Medicare paid approximately $4.5 billion for stays that had such care-plan problems. DISCHARGE PLANNING Determining the appropriate post-hospital discharge destination for a patient Identifying what the patient requires for a smooth and safe transition from the acute care hospital/post-acute care facility to his or her discharge destination Beginning the process of meeting the patient s identified pre- and post-discharge needs Discharge Planning 32 If the physician does not document medical necessity for ancillary services in their progress notes and the nurses obtain telephone orders from the physicians for ancillary services, the nurses ask the physicians for a diagnosis/reason associated with the ancillary service. Skilled programs must pay attention to ancillary cost by reviewing the costs each month The standardized ancillary cost is $116/day (MedPAC 2015) 33 11

12 Develop a Medicare educational program for all staff, not only at the time of hire but also yearly. Review Medicare documentation weekly. Provide ongoing mentoring of your nursing staff. Review the updated Medicare Benefit Policy Manual for Extended Care SNF Services. Commit, as a leader, to guarantee your systems truly reflect the Medicare documentation standards To be complete. (This implies a need to go beyond a rational diagnostic process.) 2. The they say excuse. (Who are they and do they really say that? 3. The we ll get in trouble if we don t excuse. 4. The if we don t order everything at once, it won t get done excuse, commonly given in large city hospitals. 5. The as long as he is in the hospital, we might as well excuse. 6. The academic excuse. The false idea that the evaluation of a patient should be somehow different or more complete in an academic institution. 7. The malpractice excuse. 8. The protocol excuse: the patient is a candidate for a study that requires these tests for its protocol. 9. The if it were my mother or father, I d want it done excuse. 10. The how do we know he doesn t have it? excuse. 11. The knowledge is good excuse. 12. The fishing expedition. (I don t have any idea what s wrong with this patient, but maybe if I order a lot of tests, something will turn up.) 35 For Medical Necessity Appropriate documentation Results of tests provided to physicians timely Who reviews? What education is provided? Bottom line can your ancillary services pass the test of need, cost efficiency and outcomes? How do you know? 36 12

13 Services were delivered by the institution in compliance with the Physician s plan of treatment Services are documented in health or other appropriate records as having been rendered to the patient Charges are reported on the bill accurately The health record documents clinical data on diagnoses, treatments and outcomes. It was not designed to be a billing document. A patient health record generally documents pertinent information related to care. The health record may not back up each individual charge on the patient bill. Other signed documentation for services provided to the patient may exist within the provider s ancillary departments in the form of department treatment logs, daily charges records, individual service/order tickets, and other documents. Auditors may have to review a number of other documents to determine valid charges. Auditors must recognize that these sources of information are accepted as reasonable evidence that the services ordered by the physician were actually provided to the patient. Providers must ensure that proper policies and procedures exist to specify what documentation and authorization must be in the health record and in the ancillary records and/or logs. These procedures document that services have been properly ordered for and delivered to patients. When sources other than the health record are providing such documentation, the provider should make those sources available to the auditor. 37 Based upon Center for Medicare and Medicaid (CMS) Swing Bed Providers guidelines, Georgia State Office of Rural Health identified needs, and hospital based skilled nursing and swing bed program best practices, participants will be able to: 1. Recall CMS, OIG and MedPAC data regarding ancillary services usage 2. Recognize the required documentation to support ancillary services being provided 3. Understand the importance of physician documentation to support ancillary service usage 4. Comprehend SNF consolidated billing provisions set forth by Medicare for CAH hospitals. 5. Explain how to set up a self-audit of ancillary services, including tracking usage by physicians Upcoming Live Sessions! Live RSBM Training Workshops & Hospital Consults: Focus on Compliance Includes: Swing Bed Basics, Medicare Intent, MDS and RAI Manual, RUGs/CAH Reimbursement, Medical Necessity Documentation, Case Studies/Small Groups, Identified Issues Review August 18, 2017 Cordele, GA August 25, 2017 Demorest, GA Registration now available on your program dashboard! 13

14 Program Dashboard & Ongoing Communication Online Dashboard: Password Protected: cah Ongoing Communication will come from HomeTown Health on a monthly basis. Your RSBM Team Desi Barrett, Webinar Program Manager, HomeTown Health Kristy Thomson, COO HomeTown Health Jennie Price, Director of Business Development, HomeTown Health University Kerry Dunning, Trainer & Program Director, Kerry Dunning, LLC Contact Information Desi Barrett, Webinar Program Manager hthtech@hometownhealthonline.com Kristy Thomson, COO Kristy.Thomson@hometownhealthonline.com Jennie Price, Director of Business Development Jennie.price@hometownhealthonline.com Kerry Dunning, RSBM Program Trainer Kerry.dunning@kerrydunningllc.com 14