The assisted living and skilled care industry today is going through a rocky patch. A solid half of the skilled nursing facility (SNF) industry is struggling due to Medicare Advantage, softer demand, pervasive reliance on Medicaid for census, labor shortages, rising wage pressure, tight Medicare reimbursement, and new regulations, etc. While its struggles are not as pervasive as SNFs’, assisted living is facing challenges due to softer census, overcapacity, rising resident acuity, labor costs and shortages, and increasing regulatory scrutiny. The relative strength in the overall senior and postacute sector is home health and independent housing; however, while home health demand is good, regulatory overburden is still present, along with tight reimbursement and labor challenges. Independent housing’s market and sub-market rent side remain strong; however, many high-end providers are still struggling with census challenges and soft demand in certain markets.
The following Q&A comes from the Billers' Association for Long-Term Care talk forum, Biller's Talk.
Q: Is the facility required to give a Notice of Medicare Non-Coverage (NOMNC) to a benefit-exhausted resident?
A: An NOMNC is not required by CMS regulation to be issued in relation to benefit exhaust; however, it is not wrong or held against a facility to issue one at that time. Some organizations with multiple facilities require the NOMNC to be issued as a best practice and as part of their policy and procedures, even in the event that the Medicare Part A services are terminated due to benefit exhaust.
The regulations regarding NOMNCs can be found at CMS.gov in the Medicare Claims Processing Manual, Chapter 30, Section 260.
For HIPAA covered entities (CE) that maintain poor policies and procedures related to HIPAA compliance—those that are unfinished in draft form, not updated in years, and basically not followed to the letter—their lassitude has cost them dearly.
Just look at some of the settlements OCR has struck with CEs and business associates (BA) in the past five years. Many of those settlements include findings that organizations had poorly maintained policies and procedures. This has increased the settlement amounts and in turn led OCR to issue strict consent decrees requiring these entities to update and maintain their HIPAA-related policies and procedures.
When the Centers for Medicare & Medicaid Services’ (CMS) new Patient Driven Payment Model (PDPM) goes into effect October 1, 2019, providers will have a few new acronyms to add to their dictionary, as well as some old ones that will have increased importance to quality care and reimbursement. The following list and words of advice from experts will will help you prepare.
ARD—Assessment reference date
The assessment schedule under PDPM is more streamlined and simplified than the assessment schedule under RUG-IV. The assessment reference dates are listed in Table 1 for the different Medicare MDS assessment types.