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Webinar: The Final Countdown to MDS v.1.18.11 – What You Need to Know; Hosted by Alicia Cantinieri

The final version of the MDS 3.0 RAI Manual v1.18.11 has been released as promised.  The final version contains clarifications and additional instructions not seen in the draft version, with implications for facility procedures and processes.   With the October 1, 2023, effective date rapidly approaching, interdisciplinary teams must be aware of the updated coding guidelines to ensure accurate assessment completion.  This free webinar will review the RAI Manual changes and provide best practices for ensuring compliance and making any necessary system changes for October 1streadiness.

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Note – use passcode: Z57=2T4^

PDPM Claim Probe Review: SALT Sweetens Provider Preparation

Skilled Nursing is plagued by inaccurate and inconsistent data. The Medicare claim (UB-04), while imperfect, offers a stable foundation for reimbursement analytics and even allows for cross-provider analysis. CMS uses SNF claim data to identify atypical Medicare billing patterns that reflect areas of potential concern. Specifically, its Program for Evaluating Payment Patterns Electronic Report (“PEPPER”) benchmarks utilization to guide providers through their auditing and monitoring efforts.

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2024 SNF Medicare Rates: Beware the “October Surprise”

The big news last week in SNF-land was the release of CMS’ 2024 Medicare SNF Proposed Rule. While the industry awaits guidance on (arbitrary and poorly targeted) staffing mandates, providers cheered a 3.7% reimbursement increase that adds about $24/day to the average facility’s Medicare Part A rate (we should be outraged, but I’ll cover that in August). That sentence was difficult for me to write, not only because every facility and county is different, but because the Market Basket adjustment is only one part of the annual equation; Area Wage Index (“AWI”) is the other.

Broad strokes: AWI is a federal market-specific adjustment that reflects relative labor cost differences across the nation. Some markets become relatively more expensive, some less. In other words, inflation is not evenly distributed. SNF stakeholders expecting a 3.7% rate increase may be caught off guard when the first check comes higher/lower than budgeted. This happens every year; I call it the “October Surprise” because new rates are effective for Service Dates on/after October 1st.

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Zimmet Healthcare and eCapIntel analysis on Medicare Advantage reimbursement for SNF services, relative to FFS benchmarks.

Medicare Advantage (“MA”) enrollment represents 50% of eligible beneficiaries, while another milestone commands far less attention. Despite MA’s rapid growth, the absolute number of individuals within the Medicare Fee-for-Service (“FFS”) population had also expanded; we now see FFS declining in a growing number of metropolitan areas. The trend cannot be distilled down to a single dollar value. As we explore the severity of structural deficiencies in the Skilled Nursing Facility (“SNF”) revenue-cycle, remember that Medicare Advantage is simply one example of how provider-burden differs from market to market.

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Marc Zimmet: The Inequity of Medicare Copayment

THE INEQUITY OF MEDICARE COPAYMENT is a structural deficiency in the SNF revenue-cycle unrelated to the Patient Driven Payment Model, which establishes patient-specific per diem rates across a Medicare Part A Benefit Period (up to 100 days). Medicare pays providers 100% of the PDPM rate for days 1 – 20, then applies a $200/day coinsurance reduction to the remaining (up to) 80 days. Beneficiaries without a supplemental Medigap policy must pay coinsurance out-of- pocket, which providers are required to pursue.

“Dual-eligible” beneficiaries are enrolled in both Medicare and Medicaid. Medicare Part A is the “primary” payer for qualifying SNF short-term care; Medicaid, as “secondary” insurer, is charged the $200/day coinsurance (Medicaid assumes primary-payer status after the Medicare benefit is exhausted). Federal Medicare policy is consistent across the nation; Medicaid is administered at the state level, with payment rules so variable they perversely distort the Medicare benefit Medicaid is designed to support.

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Marc Zimmet Responds To The 2023 SNF PPS Proposed Rule

Zimmet Healthcare Services Group, LLC (“ZHSG”) respectfully sets forth this response to the 2023 SNF PPS Proposed Rule (CMS-1765-5). This submission was prepared independently by ZHSG, without third-party participation or sponsorship. Perspectives are balanced across ZHSG’s multi-disciplinary experience with SNF reimbursement, market trends, and operating challenges. Claim analysis was conducted by our affiliate company Z-CORE Analytics, LLC (“CORE”); utilization from 3,000+ SNFs for services through April 2022 inform our remarks on recalibration and are specific in scope to the CMS rulemaking process.

Marc Zimmet: The 2023 SNF PPS Recalibration Adjustment

The Patient Driven Payment Model is a rare bright spot in Skilled Nursing’s dreary reimbursement landscape, but storm clouds are on the horizon. CMS has proposed recalibrating SNF rates to correct for unintentional spending relative to the RUG system it replaced. The agency refers to this reduction as a “Party” but in the context of a post-pandemic operating environment, the proposal reads more like a “Reimbursement Parody” to me…

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Marc Zimmet: The Medicaid Rate Construction Infrastructure Crisis

The codependent Medicare/Medicaid duopsony can no longer balance the SNF financial equation. Medicare Advantage, Alternative Payment Models, and ill-conceived experiments with Managed Medicaid LTC created structural deficiencies the current economic model was not designed to absorb. 

Skilled Nursing was saved from pandemic distress by emergency federal funding. Now, in the face of comprehensive reform, policymakers must fortify the industry’s reimbursement foundation. Reliable data is essential for success; without it, a decades old incongruity threatens to destabilize the entire healthcare continuum. 

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Medicare Advantage Disenrollment Trends in New York State Skilled Nursing Facilities

Medicare Advantage (MA) is a voluntary, alternative health insurance option available to Medicare eligible beneficiaries. MA is offered by a growing number of insurance companies and enrollment is expanding rapidly; in fact, MA coverage outpaces the “original” or fee-for-service (FFS) Medicare program in many markets. The “private option” offers cost savings and supplemental benefits in exchange for limitations to patients, specific to provider choice. While this cost/benefit dynamic clearly appeals to enrollees residing the community, the model generally does not create the same balance for residents of long-term care facilities. As a result, disenrollment from (or changes to specialized) MA plans is far more common in the institutional setting than the population at large.

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Marc Zimmet: The CORE Reporter, October 2021

CORE analyzes current Medicare and Medicare Advantage claims to identify reimbursement opportunities and measure a facility’s value-proposition against its peer group. As of October 1, CORE tracks Medicare performance through August 2021, while the LDS does not extend past March. CORE also delivers the same standard LDS tools, but we believe providers should not be forced to pay for access to public data; we simply include the functionality as a handy value-added service.

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