6/12/2017. The Rumor is True: A New PPS Payment System is on the Horizon Presented by: RKL, LLP Senior Living Services Consulting Group

Transcription

1 The Rumor is True: A New PPS Payment System is on the Horizon Presented by: RKL, LLP Senior Living Services Consulting Group 1 Speaker Introductions Stephanie Kessler, RAC-CT Partner skessler@rklcpa.com Tracy Montag, RN, RAC-CT Manager tmontag@rklcpa.com 2 Disclaimer The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act upon such information without appropriate professional advice after a thorough examination of the particular situation 3 1

2 Proposed Changes to Payment System 4 Proposed Payment Changes Advanced Notice of Proposed Rulemaking (ANPRM) Released by Center for Medicare & Medicaid Services (CMS) April 27, 2017 Comments for considerations must be received no later than June 26, 2017 Proposal: Change the current Resource Utilization Groups, Version 4 (RUG-IV) to a new model, The Resident Classification System Version 1 () Effective FY 2019 Begins October 1, Proposed Payment Changes Objectives: The learner will be able to: Repeat the components of the proposed RCS- 1 payment system Define the proposed Activities of Daily Living (ADL) scoring scale Identify the proposed Minimum Data Set (MDS) assessment schedule 6 2

3 Proposed Payment System Changes - Background 7 Background Current payment system Based on RUGS-IV Two case-mix adjusted components Nursing Includes the residents associated nursing and non-therapy ancillary costs based on resident characteristics Therapy Includes the resident s therapy costs based on Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) 8 Background Trends- FY2015 SNF Proposed Rule Observations on Therapy Utilization Trends memo Percentage of residents classifying into the Ultra- High therapy category has increased steadily Percentage of residents receiving just enough therapy to surpass the Ultra-High and Very-High thresholds has increased. Claims to matched MDS assessments indicated the Ultra-High minutes from 720 to 739 minutes 5% in 2005, up to 33% in

4 Background Trends Office of Inspector General (OIG September 2015 The Medicare Payment System for Skilled Nursing Facilities Needs to be Reevaluated ) Medicare payments for therapy greatly exceed the SNF s cost for therapy Created an incentive for SNF s to bill for higher levels of therapy than necessary OIG concluded that CMS should change the method of how Medicare pays for therapy 10 Background Trends March 2017 MedPAC report to Congress SNF PPS encourages the provision of excessive therapy services and does not accurately target payment for non-therapy ancillaries Overall Conclusion: The system needs to be changed and CMS must make revisions to accurately reflect both resident needs and resource utilization 11 Background CMS goals: Create a model that compensates SNF s accurately based on the complexity of the beneficiary and the resources needed to care for them; To address incentives for SNFs to deliver therapy to beneficiaries based on financial considerations, rather than the most effective course of treatment; and To maintain simplicity by limiting the number of elements used to determine payment as well as the number of assessment necessary. 12 4

5 Proposed Payment System Changes: 13 Resident Classification System -1 () Payments based on the resident s clinical characteristics rather than service provision Enhance payment accuracy; and Strengthen incentives for appropriate care Four Case-Mix Classification components are proposed Physical and Occupational Therapy Speech-Language Pathology Nursing Non-Therapy Ancillary One Non-Case Mix component Addresses consistent costs incurred by all residents 14 Physical and Occupational Therapy Case Mix Classification 15 5

6 Physical and Occupational Therapy Case-Mix Classification Most relevant predictors of PT/OT costs per day Clinical reason for the SNF stay Functional status Presence of cognitive impairment Proposed using all three predictors to determine case mix. 16 Physical and Occupational Therapy Case-Mix Classification (cont d) Step 1 Clinical reason for SNF stay MDS 3.0 Section I proposed changes PT/OT Clinical Categories Major joint Replacement or Spinal Injury Other Orthopedic Non-Orthopedic Surgery Acute Neurologic Medical Management 17 Physical and Occupational Therapy Case-Mix Classification (cont d) Step 2 Functional Status Proposed to use three late loss ADLs Transfers Eating Toileting Self-performance items only 18 6

7 PT/OT ADL Scoring Scale ADL Self Performance Score Transfer Toiletin g Eating Independent Supervision Limited Assistance Extensive Assistance Total Dependence Activity Occurred only one or twice Activity Did Not Occur Physical and Occupational Therapy Case-Mix Classification (cont d) Step 3 Cognitive Status Cognitive Function Scale (CFS) Brief Interview for Mental Status (BIMS) 15% of BIMS on 5-Day assessments are not completed Cognitive Performance Scale (CPS) Combines both CPS and BIMS from the MDS 3.0 Four cognitive performance categories 20 Cognitive Functional Scale Classification Methodology CFS Cognitive BIMS Score CPS Score Scale Cognitively Intact Mildly Impaired Moderately Impaired Severely Impaired

8 Physical and Occupational Therapy Case-Mix Classification (cont d) 30 Case-mix groups Each resident will classify into one and only one of the 30 groups Group is determined by Clinical Category, Functional Score and Cognitive status. 22 Speech-Language Pathology Case Mix Classification 23 Speech-Language Pathology Case-Mix Classification Most relevant predictors of SLP costs per day Clinical reason for the SNF stay; Presence of a swallowing disorder or mechanically-altered diet; and Presence of a SLP-related comorbidity or cognitive impairment Proposed using all three predictors to determine case mix. 24 8

9 Speech-Language Pathology Case-Mix Classification (cont d) Step 1 Clinical reason for the SNF stay Acute neurologic or Non-neurologic Step 2- Presence of a swallowing disorder or a Mechanically-altered diet. Considering classifying residents as having either a swallowing disorder, being on a mechanically altered diet, both or neither for purposes of classification in the SLP component 25 Speech-Language Pathology Case-Mix Classification (cont d) Step 3 Presence of cognitive impairment or SLPrelated comorbidity CFS to determine cognitive impairment SLP-related Comorbidities Aphasia Laryngeal cancer CVA, TIA, or Stroke Apraxia Hemiplegia or Hemiparesis Dysphagia Traumatic Brain Injury ALS Tracheostomy (while Oral Cancers resident) Ventilator (while resident) Speech and Language deficits 26 Nursing Case Mix Classification 27 9

10 Nursing Case-Mix Classification 43 Nursing indexes Uses the RUG-IV Nursing Categories Extensive Services Special Care High Special Care Low Clinically Complex Behavior Systems & Cognitive Performance Reduced Physical Function 28 Non-Therapy Case Mix Classification Non-Therapy Ancillary Case-Mix Classification 28 Different Conditions identified Based on point system Sum of the points will assign the resident into a Non-therapy ancillary classification. NTA Score Range NTA Group NTA Case-Mix Index 11+ NA NB NC ND NE NF

11 Case Mix Classification 31 Payment Classification Each resident is classified into four components (PT/OT, SLP, Nursing and NTA) Single Per diem payment based on the classifications Payments will better align with resident need Payment Proposal PT/OT component payment will start to decrease 1% every three days after day 14. NTA component payment will decrease beginning day 4 of stay. 32 MDS Assessment Schedule 33 11

12 Assessment Schedule proposal Goal: to decrease assessment burden Proposing: 5-day assessment only Discontinue unscheduled assessments Significant Change in Status Assessment PPS Medicare Part A Discharge Assessment Medicare MDS Assessment Schedule Type 5-day Scheduled PPS Assessment Significant Change in Status Assessment (SCSA) PPS Discharge Assessment Assessment Reference Date Day 1 8 No later than 14 days after a significant change is identified Equal to the End Date of the Most Recent Medicare Stay (A2400C) Applicable Standard Medicare Payment Days All covered Part A days until Part A discharge (unless a Significant Change in Status Assessment is completed) ARD of the assessment through Part A discharge (unless another SCSA is completed) N/A Case Mix Classification Additional Proposed Changes 36 12

13 Potential Revisions to Therapy Provision Policies under the SNF PPS CMS is considering setting a 25 percent limit on concurrent therapy, in addition to the 25 percent limit on group therapy that was established at the inception of the SNF PPS CMS is considering making the concurrent therapy limit discipline specific. For example, if a resident received 800 minutes of physical therapy, no more than 200 minutes of this therapy could be provided on a concurrent basis and no more than 200 minutes of this therapy could be provided on a group basis 37 Interrupted Stay Policy Payment adjustment when a resident is temporarily discharged from the facility during the Medicare Part A stay and returns within a specific time frame Return to the same SNF within 3 calendar days, after have been discharged, CMS is considering this as a continuation of the previous stay The resident s classification will remain the same as prior to discharge no new 5-day assessment required Return more than 3 calendar days, the readmission would be considered a new stay New 5-day required to set payment 38 i Interrupted Stay Policy Example A: A beneficiary is discharged from a SNF stay on Day 3 of admission. Four days after the date of discharge, the beneficiary is then readmitted. The SNF would conduct a new 5-day assessment at the start of the second admission and reclassify the beneficiary accordingly. In addition, for purposes of the variable per diem adjustment schedule, the payment schedule for the second admission would reset to Day 1 payment rates for the beneficiary s new case-mix classification

14 Interrupted Stay Policy Example B: A beneficiary is discharged from a SNF stay on Day 7 and is readmitted to the same SNF before midnight of the date 3 calendar days from the day of discharge. For the purposes of classification and payment, this would be considered a continuation of the previous stay (an interrupted stay). The SNF would not conduct a new assessment to reclassify the patient and for purposes of the variable per diem adjustment schedule, the payment schedule would continue where it left off; in this case, the first day of the second stay would be paid at the Day 8 per diem rates under that schedule 40 Potential Impacts of Implementing RCS-I CMS acknowledges the possibility that, as therapy payments under RCS-I would not have the same connection to service provision as they do under RUG-IV, it is possible that some providers may choose to reduce their provision of therapy services to increase margins under RCS-I CMS acknowledge that a number of states utilize some form of the RUG-IV case-mix classification system as part of their Medicaid programs and that any change in Medicare policy can have an impact on state programs 41 Preparing Now 42 14

15 Prep for Do not change current processes until the Final Rule is released. If finalized: Consider MDS review/training. Ensure the BIMS is being completed within the first eight days (or on or before the ARD) for the 5-day assessment Section I Active Diagnosis coding Ensure the codes are accurate and correctly reflect the reason the resident is in your facility for skilled care Education for the members of the interdisciplinary team 43 Questions?? 44 Contacts Stephanie Kessler Partner Skessler@RKLcpa.com Tracy Montag Manager TMontag@RKLcpa.com