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“If you look at who the primary group responsible for overpayment is when you’re looking at hospitals, hospice, home health, and hospital/outpatient in skilled nursing facilities, you can see that [SNFs’] rate here is much higher than the other entities,” said Alicia Cantinieri, vice president of MDS policy and education for Zimmet Healthcare Services Group. “That’s why they’re looking at us.”

Improper payment rate is a measure of payments that don’t meet the Medicare requirements for whatever reason, she said. It’s not the same thing as fraud rate.

Zimmet, in partnership with Simple, hosted a webinar Monday on the improper payment probe, which included advice on how SNFs can spot errors through internal audits.

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The Centers for Medicare & Medicaid Services (CMS) took aim at improper skilled nursing payment rates in its latest memo on May 4.

This appears to be a reaction from data compiled using the Comprehensive Error Rate Testing (CERT) program, which projected an improper payment rate of 15.1% in 2022 for Medicare Fee-for-Service (FFS), nearly double compared to 7.79% in 2021.

“They felt the error rate was so high that they needed to check everyone,” Alicia Cantinieri, vice president of MDS policy and education for Zimmet Healthcare Services Group told Skilled Nursing News.

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As Medicare Advantage continues to penetrate the nursing home market, leaders say that MA plans are depressing margins amid higher costs to run operations. This might lead some operators to contemplate closing, while others will be wiser to hire staff in designated roles to help them negotiate better rates – and exclusions – for managed care contracts.

Data confirms that managed care rates are bringing down margins in the space, with MA plans paying one-quarter to one-third less to SNFs than traditional Fee-for-Service (FFS) Medicare, according to statistics put out by the National Investment Center for Seniors Housing & Care (NIC) and published in a Forbes piece by Howard Gleckman, also a senior fellow in the Urban-Brookings Tax Policy Center at the Urban Institute, where he edits the fiscal policy blog TaxVox.

Traditional Medicare amounts to nearly $600 per resident day in revenue, while managed Medicare is paying out only $468 per day, NIC data shows.

This means that the ‘game is already on’ for this measure since the baseline period was FY 22,” said Steven Littlehale, RN, chief innovation officer at Zimmet Healthcare Services Group, who put national nurse staff turnover at 54%.

“Whatever support the government can offer to providers to incentivize staff retention is appreciated; however, we need more carrots and fewer sticks,” Littlehale told McKnight’. “Additional regulation is not the answer to this quagmire.”

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“We have to keep in mind that more measures don’t necessarily mean better care,” said Melanie Tribe-Scott, BSN, director of quality innovations at Zimmet Healthcare Services Group. “It’s really the quality of the measure we’ve got to look at, and things change over the years so the measures should change too.”

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In 2016, the Centers for Medicare & Medicaid Services started focused on-site surveys to address the issue of erroneous coding of schizophrenia in nursing homes.

More recently, the agency began conducting off-site audits to assess the accuracy of Minimum Data Set (MDS) data. They are currently examining nursing homes’ evidence for appropriate documentation, assessment, and coding of residents’ schizophrenia diagnoses.

If CMS identifies inaccuracies in a nursing home’s MDS coding, the facility’s Five-Star rating will be downgraded by one star for six months, which can negatively impact admissions, jeopardize community partnerships, and draw attention from other external stakeholders. However, even more concerning is how these coding problems affect residents.

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“The Physician’s Desk Reference actually shows indications for using antipsychotics for bipolar disease I and II, neurocognitive symptoms associated with borderline personality disorder, Lewy body neuropsychotic symptoms. We even have Nuplazid, which was approved by the FDA in 2016 specifically for the treatment of Parkinson’s psychosis,” said Melanie Tribe-Scott BSN, vice president of Quality Initiatives at Zimmet Healthcare Services Group.

Being torn between taking patients off needed medications and being penalized for it, or choosing another diagnosis that would be excluded from the quality measure “is kind of where this whole issue is coming from now, partially,” said Alicia Cantinieri, vice president of MDS policy and education for Zimmet.

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Poor support of staff contributes to a negative reputation in the community, complaints to an ombudsman or the local department of health, or even whistleblower complaints, among others. As a result, your facility might experience undesired resident outcomes, a lawsuit, an allegation of criminal actions, or investigations by external oversight agencies.

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“The nuanced details really matter,” said Steven Littlehale, a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

Virginia’s use of payroll-based journal data plus its inclusion of nursing directors and others who perform administrative as counting toward the daily hours duties differs from other states. It also links the staffing requirement to facilities’ Medicaid value-based purchasing program.

“Simply put, [nursing homes] have financial incentives to meet the staffing requirement,” said Littlehale, an expert columnist at mcknights.com.

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