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.
When trying to understand something complex, it sometimes helps to use food as a metaphor. Under the Patient-Driven Payment Model (PDPM), therapy becomes a piece of the pie, rather than the whole thing. For providers considering ways to minimize therapy services or reduce therapy staffing, a few additional considerations should be looked at before making any cuts.
Developing a proactive internal approach to identifying and correcting billing issues before they become problematic is always good practice. Education and training on billing, coding, and documentation are essential. And as with any solid system, success depends heavily on continued monitoring of the process.
The UB-04 is made up of form locators (FL), or boxes to be completed. Some of the FLs are required, some are optional, and some are not used in the SNF setting. If any required pieces are missing, the claim will not pass the system edits when it is submitted to the MAC. Although most Medicare billing is done electronically and the UB-04 is completed largely by the billing software, it is important for Medicare billers to be familiar with the pieces of information required on the claim and how to complete the form.
When a Medicare Part A beneficiary is absent but not discharged, for reasons other than hospital or other SNF admission, a leave of absence (LOA) bill is required. The day of discharge, the day of death, or the day on which a beneficiary begins an LOA is not counted as a utilization day and is not billed. The exception to this rule is when the beneficiary is admitted to the SNF with the expectation that he or she will remain overnight but is discharged, dies, or is transferred to a nonparticipating provider before midnight of the same day.