Webinar Etiquette. Webinar Resources

Transcription

1 Georgia State Office of Rural Health & HomeTown Health, LLC Welcome you to the: Best Practices for Compliance & Efficiency Rural Swing Bed Management (RSBM) Training Program Use of Swing Beds in PPS Hospitals: Focus on Medicare This project is supported by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) grant number 16062G. Webinar Etiquette All attendees are in Listen Only mode Questions or comments? - Open Questions pane in dashboard - Type in comments or questions - Comments will be monitored through out webinar. - Questions will be addressed at end of the webinar. Webinar Resources This webinar will be recorded and ed to you to share with others on your team. Handouts are available for download in the Handouts pane, and were ed to registered attendees this morning. Please let us know if you did not receive the . 1

2 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: Attend webinar/view recording in its entirety within 30 days Pass online quiz with 80% or better. Complete webinar evaluation. Continuing Education Unit Conditions Following this webinar, all attendees who have viewed the recording in its entirety will receive an with an HTHU.net link to the optional webinar recording, online quiz, online evaluation and online certificate of completion. Anyone that misses the webinar or attended less than 90% of the live webinar will receive an with the webinar recording and steps to obtain CEUs. New to HTHU? Register for Free, Make sure to select your hospital from the Organization Dropdown Returning Students? Login Continuing Education Unit Conditions Are you attending in a group? Please add other attendees first name, last name and address in the Questions pane. 2

3 Agenda Welcome & Introduction Desi Barrett, Webinar Program Manager Use of Swing Beds in PPS Hospitals: Focus on Medicare Presentation Next Steps Dashboard & Calendar Kerry Dunning RSMB Program Trainer Kerry Dunning, LLC Desi Barrett, Webinar Program Manager Kerry Dunning, MHA, MSH, CPAR, RAC-CT 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. Contact Kerry at: or Kerry.dunning@kerrydunningllc.com Kerry Dunning, MHA, MSH, CPAR, RAC-CT Kerry Dunning LLC November

4 Description: This webinar will review the key elements required by Medicare for a swing bed program including Medicare Intent, Conditions of Participation, CMS and Federal Regulations, required Medicare documents, Medical Necessity and documenting requirements, and an introduction to the RSBM Dashboard. Objectives: 1. Review the Conditions of Participation and address overlooked requirements 2. Know the 5 required Medicare paperwork documents and other key regulations 3. Learn the CMS definition of medical necessity documentation 4. Begin to collect and track Dashboard data necessary for future Swing Bed business 10 Opportunity to ask questions If you are not sure you are doing it correctly AND you do not want to say so publicly... listed at the end 11 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. Lisa Carhuff, Director of Hospital Services, Georgia State Office of Rural health obtained the grant HomeTown Health is managing the grant for SORH 12 4

5 Therapy Patient Admissions ranged from 100% to less than 10% Nearly 60% said therapy admissions account for more than 80% of the swing bed admissions Of the first diagnoses listed by each participating site even though they were primarily therapy patients over 70% named CHF COPD Pneumonia Average Length of Stay (ALOS) ranged from 2.9 days to two weeks Admissions from your own hospitals started only 1% to 88% 13 Access to health care is important, and as the gap widens between urban and rural, SWBs reduce the chances of closure Rural Hospitals treat some of the sickest patients Helps avoid rehospitalizations The greatest strength is the breadth of primary care services to care for more patients locally across the care continuum Looking at creative ways to use more swing beds as acute census declines Important to the community Time sensitive stabilization (disproportionate % of trauma deaths occur in rural areas) Community jobs 14 Payment for bed utilization equates to more than an empty bed Assists with DRG management Excess capacity in staffing most often allows you to provide this new service without increasing staff cost Assists with ancillary staffing productivity Avoid transfer rules 15 5

6 Skilled level care to identify patient needs and address safety issues More time for family education Increased patient/family satisfaction Return from larger hospital to home area 16 Return of residents to area nursing homes when possible Nursing Homes are frequently not staffed or equipped to offer comprehensive skilled care patient s acuity may be too high for a community-based SNF Home Health is paid a specific amount per 60 days regardless of needs, hence do not object to a few extra days in the hospital to decrease acuity and increase stabilization Home Health are paid under PPS by discharge 17 Hospital systems are looking for partners to help manage the post-acute needs CJR and other Bundling directives Time to be working with referring hospitals Insurance companies looking for skilled nursing option Do you know what is going on with your area SNFS? 5-Star rating? Staffing ratios? Quality Measures? Regardless, must be ready to provide all services 18 6

7 Types of Data ALOS ADC Cost per episode Outcomes Return to hospital within 30 days (from home or home health) Care Coordination and Quality Improvement Looking for handoffs between hospital and post-acute settings Patient satisfaction Quality Measures

8 Train to CMS rules Medical Necessity documentation Medicare required paperwork Understanding Medicare intent Most Common Use of Swing Beds: Need was for physical and occupational therapy for orthopedic patients Patients needing strengthening following their hospital stay Patients requiring wound care Patients getting intravenous antibiotics 22 SOM Appendix T Special Requirements for Hospital Providers of Long-Term Care Services ( Swing-Beds ) The facility is substantially in compliance with the following skilled nursing facility requirements contained in subpart B of part 483 of this chapter. (1) Resident rights ( (b)(3) through (b)(6), (d), (e), (h), (i), (j)(1)(vii) and (viii), (1), and (m) of this chapter). (2) Admission, transfer, and discharge rights ( (a) of this chapter). (3) Resident behavior and facility practices ( of this chapter). (4) Patient activities ( (f) of this chapter), except that the services may be directed either by a qualified professional meeting the requirements of (f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy. (5) Social services ( (g) of this chapter). (6) Comprehensive assessment, comprehensive care plan, and discharge planning ( (b), (k), and (l) of this chapter, except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under (b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in (b) of this chapter). (7) Specialized rehabilitative services ( of this chapter). (8) Dental services ( of this chapter). 23 The same rules apply to the Swing bed patient as they do for the Skilled Nursing facility. Enrolled in Medicare Part A Benefit days available to use Within 30 days of discharge from the hospital Requires 3 midnight acute stay (no OBS) Need for skilled care on a daily basis provided by or under the direct supervision of skilled nursing or rehabilitation professionals Nursing x 7 days/week and/or Physical Therapy x 5 or more days/week 24 8

9 The provisions of the MSP may be found at 42 U.S.C. 1395y (b) and mandatory Insurance Reporting requirements were enacted by Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( MMSEA ) For Medicare to render payment for skilled services provided to a beneficiary during a Medicare Part A Stay it must be completed Completed at Registration/Admissions Must have a new MSP for a swing bed stay 25 Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services= Medical Necessity The certification /recertification of the treatment plan is the technical requirement for payment, not the referral. If not completed, it is an automatic denial on Medical Review. (Rev. 1, ; SNF Manual Chapter 2, Section Coverage of Services) As a practical matter the services can only be provided on an inpatient basis in a Swing Bed or Skilled Nursing Facility Patients are admitted to a Swing Bed Program if they are not at an acute level of care any longer (i.e. medically stable and no longer require telemetry)

10 Care as determined by physician must be medically necessary and certified/recertified by a physician Certification: Must be signed and dated on admission Recertification: Must be signed and dated on or before the14th day of skilled care and every 30 days thereafter Physician must date the certification on the date he actually signs it-it may be faxed Certifications may be signed by physician, ARNP or PA working in collaboration with a physician who does not have an employment relationship with the SNF Stamped signatures are not allowed Handwriting must be legible For an item or service to be considered medically necessary, it must be: (1) Consistent with the symptoms or diagnosis of the illness or injury under treatment; and (2) Necessary and consistent with generally accepted professional medical standards (i.e., not experimental); and (3) Not furnished primarily for the convenience of the patient or the physician; and (4) Furnished at the most appropriate level that can be provided safely and effectively to the patient

11 Medical necessity documentation is a compliance issue for all healthcare providers Two troubling aspects of this issue are: Medical necessity is subjective an judgments must be made For Medicare and other third party payers, the judgment of medical necessity is made after the fact Insufficiently Explanatory 31 The following consents, at a minimum, should be obtained on admission to Skilled Care. Consent to Treat Patients must give consent for treatment, verifying the patient has been fully informed regarding the benefits and risks of any procedure or treatment. 45 CFR 164, 42 CFR, CH IV, Part 483 Consent to Bill Consent for Medical Records Release Consent to Photograph Consent for Release of Information from Social Security 32 MDS assessments are required for Medicare payment (Prospective Payment System [PPS]) purposes under Medicare Part A (described in detail in Section 2.9 In the RAI Manual). Acceptable ARD date RUG Classification New MDS October 1 (more than Section GG changes) Facility Final Validation Report Error messages Fatal errors Warnings 33 11

12 Regulation: Medicare Services Manual General (Rev. 73, Issued: , Effective: , Implementation: ) Skilled physical therapy services must meet all of the following conditions: The services must be directly and specifically related to an active written treatment plan that is based upon an initial evaluation performed by a qualified therapist after admission to the SNF and prior to the start of therapy services in the SNF that is approved by the physician after any needed consultation with the qualified therapist 34 The services must be provided with the expectation, based on the assessment made by the physician of the patient s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist The services must be reasonable and necessary for the treatment of the patient s condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable. 35 The therapist, in conjunction with the written Plan of Care, provides therapy services to the patient. The minutes provided are kept in a log or on the daily treatment sheets. Those minutes are then reported to the MDS Coordinator to enter into the MDS The minutes provided MUST match the minutes entered into the MDS 36 12

13 Services delivered to a Medicare beneficiary are to be reduced or terminated following delivery of covered care, or thought not to be covered under 1862 (a) (1) of the Act, in order to shift liability under 1879 of the Act Providers must give these notices before services are delivered for which the beneficiary may be liable Failure to provide such notices when required means the provider will not be able to shift liability to the beneficiary 37 Different than the Important Message from Medicare Deliver 2 days prior to discharge even if they agree with the termination of services Applies to Medicare & Medicare Advantage/Combined to one notice ABN is given if the patient decides to continue with services once the decision is made Do not give when benefits are exhausted or reduced Patient has right request an expedited review by the QIO; Form CMS If requested deliver by close of business day they day you are notified Do not routinely give notice at the time services begin unless the service is expected to last fewer than two days

14 PRE-ADMISSION Not extended IP stay Reducing medication cost Medical Necessity No standing labs or unnecessary x-rays RT versus Nursing staff MDS Management Right RUG Right days (i.e., not less than 5 day stays) 40 Covered Individual Covered service or item Ordered by a physician or qualified practitioner Medically necessary Provided by qualified facility or healthcare personnel Appropriate Documentation Billing privileges with the Medicare Program Proper claim, filed timely RECOMMEND TRIPLE CHECK 41 Chapter 8, Medicare Benefit Policy Manual Chapter 6, Medicare Claims Processing Manual Code of Federal Regulations, Social Security Laws (Titles 18 & 19) Corporate Compliance QAPI HIPAA 42 14

15 Social Admits/Custodial Care are not swing bed patients Physician did not certify or recertify 3-Day Qualifying Stay not met Other: More than 30 Days have passed since discharge from 3 Day Qualifying Stay Benefits Exhausted Benefit Period has ended NOMNC not given to patients Claim submitted for a days of SNF care but documentation does not support SNF care received Documentation from physician states patient no longer needs SNF care & is ready to go home

16 Program Dashboard & Ongoing Communication Online Dashboard: Password Protected: pps 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 16