CRITICAL ACCESS HOSPITAL SWING BED PROGRAM Operational and Management Strategies March 1, 2016 Andrea Elliott, CPA Senior Managing Consultant aelliott@bkd.com Suzy Harvey, RN-BC, RAC-CT Managing Consultant sharvey@bkd.com
Agenda Coverage Criteria Swing Bed Management & Utilization Important items for SB Cost Reports CAH Financial Ratios CCJR Questions 2
Skilled Nursing Facility vs CAH Swing Bed Level of Care
Level of Care Swing beds must meet same level of care criteria as Skilled Nursing Facilities SB SNF
Operational Benefits Provides viable option to local community Increased in-house services for the community Physicians can easily monitor their patients without moving them Keeps patients in the community Helps to manage Nursing hours with less drastic fluctuation in the census Cost-based reimbursement No length of stay requirements
Patient Benefits of Swing Bed Improved Patient Care Opportunity to identify patient needs to assure safe and sustainable return home More time for training, demonstration, return demonstration, education to patients and family Extra time to put post-acute discharge plan in place Increased patient/family satisfaction ( not thrown out ) Willingness to go to a skilled level of care while meeting their needs for a longer inpatient stay
Resources The policies for extended care services in a Swing- Bed are the same as a SNF. Medicare General Information, Eligibility and Entitlement Manuals Chapter 3, Section 10.4 Chapter 4, Section 40 Medicare Benefit Policy Manual Chapter 8, Sections 10,20,& 30 Chapter 15, Section 220 State Operations Manual Appendix W
Coverage Criteria
Technical Eligibility Medicare Part A available days Medicare Advantage Plan or Managed Care Three consecutive day qualifying stay in acute hospital (3 midnights) within the last 30 days 30 day Transfer Rule Medically appropriate exception Physician Certification
Clinical Eligibility Skilled Services performed or supervised by a qualified technical or professional health personnel For a condition, which arose while receiving care for a conditions for which he received inpatient hospital services Services required Daily Skilled Nursing Services 7 X week Skilled Rehabilitation Services at least 5 X week Reasonable and necessary
Skilled Services Defined Nursing or Therapy services Furnished per physician order Require skills an d qualification of professional personnel Provided directly by or under supervision of skilled personnel
Determining Skilled Services Skilled level of care is usually required because of the patient s condition, which may: Be unstable Require complex treatment Be associated with multiple unskilled problems which demand professional management Be a chronic situation that confines the patient and requires ongoing nursing decisions about services on a daily basis or Terminal, meeting the requirements of skilled care.
Nursing Services - Skilled Direct Skilled Nursing Services Care Plan Management Observation and Assessment Teaching and Training
Questionable Situations Situations that do not support evidence of daily skilled service Primary services needed is oral medications Patient is capable of independent ambulation, dressing, feeding and hygiene Therapy for strength and endurance Passive ROM
Swing Bed Management & Utilization
Inquiry/Initial Pre-Assessment Process Process should begin day 1 of acute hospital stay. Hospital discharge planner, along with UR committee, review all acute patients-daily Identify patients eligible for SB Notify Physician of SB eligibility Notify Patient or Representative
Patients in ER/Observation Utilizing the 30 Day Transfer Rule Has the patient been in the hospital or received skilled care in the past 30 days? Is the reason for ER/Observation related to the most recent hospital stay? Admit to Swing Bed 17
Swing Bed Tracking Form Recommend use of; Tracking form Good way to determine type of patients not being admitted Great for marketing Pre-screening form Examples of both included in handout
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Manage care needs Utilization Review Ensure stability prior to discharge Monitoring acute stay for 96 hour requirement or GMLOS of diagnosis Look at length of stay Typically less than 5 days Increase to 7-10 days for safe and sustainable discharge 22
Summary Risk management is essential for effective utilization of Swing Beds Verify all eligibility criteria is met Documentation to Support Skilled Care Manage the patient stay Ensure safe and sustainable discharge Increase length of stay as appropriate to prevent rehospitalizations 23
Swing Bed Financial Implications
CAH Cost Report Important Items Importance of reporting correct patient days: CAH cost per day Observation days (typically calculated based upon hours patient is in observation) must be correct to allocate costs for this service outpatient service Report Medicare HMO days (Acute Part C) to increase Medicare utilization for EHR payments
CAH Cost Report Important Items Importance of reporting correct patient days: Should also segregate Medicaid HMO days from straight Medicaid for those receiving Medicaid DSH (for tie out to audits by the state) Exclude days related to self-insured insurance plan NF days paid consistent with Medicare rates should be included on the SNF line
CAH Cost Report Important Items Importance of reporting correct patient discharges: Discharges must be correct for CAH average length of stay calculations Plan to track hours patients are in-house as acute, if length of stay is approaching 96 hours EHR importance for Medicaid
CAH Cost Report Important Items Reporting correct days example: Routine cost $ 984,560 Routine days total 1,075 (error of 10 days) Cost per day $ 915.87
CAH Cost Report Important Items Reporting correct days example: Routine cost $ 984,560 Routine days total 1,065 (correct days) Cost per day $ 924.47
CAH Cost Report Important Items Reporting correct days example: Routine cost per day (correct) $924.47 Routine cost per day (error of 10 days) $915.87 Error per day $8.60 Medicare acute/swing bed days 635 Reimbursement impact $5,461
CAH Cost Report Important Items Accurate matching revenue and expense Revenues and expenses should be properly matched on the cost report (line numbers) Proper and consistent cut-off of both revenue and expenses for your year-end Following asset capitalization policy for new assets and repairs
CAH Cost Report Important Items Physicians Important to be proactive to correctly capture all physician costs for the cost report. ER availability time studies (write into contract that this is a requirement) Medical Director time studies or contract language ER Call Pay contract language and time study
CAH Cost Report Important Items Statistics B part I is a summary of all costs as allocated by the B-1 statistics. The data can be used for more than just the cost report. Review these allocations for changes from year to year and also what is going to non-reimbursable cost centers.
CAH Financial Ratios What is your total occupancy rate? What is your length of stay? What is your swing bed length of stay? What is your opportunity?
CAH Financial Review
CAH Financial Review
CAH Financial Review
CAH Financial Ratios Occupancy rate (4,021/9,125) 44.1% Length of stay (4,021/1,018) 3.95 Swing bed length of stay (557/93) 5.99 Medicare Percentage (2,311/4,021) 57.5% There appears opportunity to increase patient utilization of the swing beds, as many SNF providers see ALOS of 10-14 days. If could add 4 days to LOS would result in 372 additional days.
CAH Financial Revised Ratios Occupancy rate (4,393/9,125) 48.1% Length of stay (4,393/1,018) 4.32 Swing bed length of stay (929/93) 9.99 Medicare Percentage (2,683/4,393) 61.1%
CAH Financial Results Medicare Days Medicare Discharges Medicare ALOS Total Days Medicare Days Medicare Discharges Medicare ALOS Total Days Acute/ICU 1,754 483 3.63 3,464 1,754 483 3.63 3,464 Swing Bed - SNF 557 93 5.99 557 929 93 10 929 Swing Bed - NF - - - - Observation - 528-528 Total Days 2,311 4,549 2,683 4,921 Total Routine Cost 4,879,006 4,879,006 Less: Swing Bed - NF Costs - - Adjusted Total Routine Cost 4,879,006 4,879,006 Total Days (Less Swing Bed - NF) 4,549 4,921 Total Routine Cost Per Day 1,072.54 991.45 Medicare Days 2,311 2,683 Medicare Acute & Swing Bed SNF Cost 2,478,651 2,660,136 Medicare Routine Cost Reimbursement % 51% 55% 181,485
Comprehensive Care for Joint Replacement (CCJR) CAH s are not subject to CCJR HOWEVER CAH s in CCJR MSA s should not expect admissions into their swing beds from other acute hospitals based on the high cost of service (as compared to skilled nursing facilities and home health agencies) CAH s should monitor legislation as other MSA s and other DRG s are added which could impact referral sources
Summary Cost report is important for more than just the settlement Provides important management information It is important that the individuals involved in preparing the cost report understand the importance of all the issues surrounding CAH reimbursement Monitor CAH reimbursement on an interim basis to avoid significant under/over payments at year end
QUESTIONS?
THANK YOU! FOR MORE INFORMATION Andrea Elliott, CPA aelliott@bkd.com 417-865-8701 Suzy Harvey, RN-BC sharvey@bkd.com 417-865-8701