When it comes to knowing the difference between inclusions and exclusions in Consolidated Billing (CB), it can be extremely confusing for SNFs. Let’s first break it down by the basics. Included refers to items or services that are included in CB and for which the SNF must pay the outside vendor for specific services they provide. Excluded refers to items or services that are excluded from CB and may be billed by the outside vendor directly to Medicare Part B. Sometimes these items or services are also referred to as carve-outs.
With the October 1, 2019 go-live date for the Patient Driven Payment Model (PDPM) just months away, providers are anxious to learn of any updates or clarifications CMS will make prior to the new model taking effect. As such, many providers were relieved when CMS released the mid-year draft of the MDS 3.0 Resident Assessment Instrument (RAI) Manual v1.17 on May 20.
In nearly all provider segments of healthcare, revenue maximization and integrity are directly tied to compliance and quality ratings. In home health, submission of quality data via the OASIS (known as HHCAHPS) is required. Agencies that fail to submit the required data receive reimbursement reductions of 2%. For SNFs, reporting QRP data is required. Failure to meet the 80% threshold reporting requirement on quality measures equals a 2% payment reduction (beginning October 2019). The cutoff date to meet the compliance level for the period of October 1–December 31, 2018 was May 15, 2019; too late for facilities that underperformed.
Although nursing services is often the biggest cost center to be managed in a long-term care facility, one cannot overlook many of the other areas that need to be closely scrutinized. One area that can be an albatross for many administrators is preventing runaway costs in the dietary area. In particular, food costs are a major concern. Furthermore, administrators have to maintain adequate staffing in areas such as housekeeping, maintenance, laundry, and physical and occupational therapy and yet avoid overstaffing that could incrementally increase costs. This chapter will discuss some of these important areas and how their costs could be managed.
October 1 will be here before we know it. And with that comes Medicare’s new Patient-Driven Payment Model (PDPM) for beneficiaries accessing their skilled nursing facility (SNF) Part A benefit. It seems like every day there is a new webinar being advertised to help you understand the ins and outs of PDPM, but if there’s one thing you can know without any training, it’s that the new payment model is a much more complex system than the resource utilization group, version IV (RUG-IV) system that we operate under currently. As we analyze data collected in our facilities trying to understand our place in a PDPM world, though, don’t forget this important consideration: your therapy contract.