My father died a little over a year ago. While I usually derive tremendous comfort and support by sharing both happy and sad milestones with friends, family, and colleagues, in this instance, sharing the news earlier would have just been too hard. His death was about one year after receiving a diagnosis of inoperable pancreatic cancer, just one year after he sent me a video of his jaundiced body asking me what he should do.
Properly capturing degrees of acuity within the industry’s two major payers, Medicare and Medicaid, and having acuity accurately and consistently represented and understood in data, is an area that needs attention, Marc Zimmet told Skilled Nursing News. Acuity levels are, after all, impacted by previously missed diagnoses for certain conditions.
“Respiratory therapy is a classic example. It’s a very powerful reimbursement driver. It’s not that patients weren’t getting respiratory therapy nebulizers [before the pandemic or PDPM]. It’s that we got a lot better at documenting and capturing it and that makes the patients look sicker,” said ZImmet, CEO of Zimmet Healthcare Services Group.
Every skilled nursing facility in the US will be subject to a five-claim audit starting the week of June 5 as regulators try to better assess and root out improper payments….
But the improper payments can’t be attributed to PDPM alone, said Alicia Cantinieri BSN, vice president of MDS policy and education for Zimmet Healthcare Services.
“That’s probably not the whole reason,” she said on a webinar earlier this month.
She noted that risk areas that could move providers to the front of the audit process include past performance, such as a history of additional documentation requests (or ADR); frequent errors in Section GG, which sets payment rates for physical therapy, occupational and nursing groups; diagnoses without medical record to support MDS inclusion; and even illegible RN signatures.
“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.
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.
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.
When I read my first SNF PPS final rule about 25 years ago, I thought that the start dates for some of its initiatives were so far in the future that they were of no concern. As a young person, my long-range planning didn’t extend beyond that evening’s dinner or weekend activities.
Today, when I read the most current proposed SNF rule for fiscal year 2024, with program initiatives starting as far out as FY 2027, I think, “Surely I’ll be retired by then, or even worse!” But long periods of time pass as quickly as the setting sun, and even initiatives scheduled to begin years away require our attention now. Such is the case with the proposed new measures in the SNF Value-Based Purchasing program.
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.”
“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.”