Reg's Blog

Senior and Post-Acute Healthcare News and Topics

Webinar – Post-Election Healthcare Policy: What to Expect

Join me as I host a one-hour webinar and conference call regarding post-election healthcare policy.  The program/call is set for Wednesday, December 14 at 1:00 PM EST/noon CST.

With uncertainty looming, providers are wondering what will change as the Inauguration approaches and a new Congress settles in. We will review the ACA, Medicaid and Medicare, and related policy issues including;

  • Value Based Purchasing
  • CMS Center for Innovation/Alternative Delivery Models/Bundled Payments
  • Additional Quality Measures and Quality Reporting
  • Inter-Program and Payment Reform – Rate Equalization for Post-Acute Providers
  • IMPACT Act
  • ACO Expansion

The program is sponsored by HCPro and the registration link is below;

 http://www.longtermcarebillers.com/content/join-us-quarterly-biller%E2%80%99s-association-webcast

 

December 6, 2016 Posted by | Policy and Politics - Federal | , , , , , , , , , , , , , , | Leave a comment

Conference Presentation

In September, I spoke at the Kairos Health conference in Pennsylvania on request/behalf of HCPro.  The topic was on upcoming/current regulatory and compliance issues in Post-Acute Care.  By request, I am providing the presentation on this site.  Readers can find it on the Reports and Other Documents Page.  The title is “Upcoming Post-Acute Regulatory Issues”.  It is free for viewing or download.  As always, questions, comments, etc. feel free to comment to this post or drop me a note at the email address provided on the Author page of this site.

October 13, 2016 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , | 1 Comment

Webinar on Preventing Hospitalizations/Re-Hospitalizations

Next week – Wednesday, October 5 – I am conducting a webinar on behalf of HCPro on the subject of preventing unnecessary hospitalizations.  The program will cover all care transitions with a particular emphasis on inpatient admissions.  Below is a quick summary about the program.

The new quality measures are out, and there is a renewed emphasis on reducing the risk of avoidable hospitalizations and readmissions. Across a number of regulatory elements beginning this year, hospitalization and readmission rates from SNFs will be measured and ultimately factored into the SNF landscape via reimbursement penalties and star ratings.

At the conclusion of this program, participants will be able to: 

  • Identify the steps that lead to readmissions and what can be done to lessen or eliminate the risk 
  • Increase their awareness of the tools available to reduce the risk of readmissions 
  • Use best practices to improve care coordination 
  • Know which key elements produce readmissions and how to limit or remove them, including medication reconciliation, care conference structure/strategy, care pathways, disease management programs, and communication tools 

Registrants get the session content plus handouts which include usable QA tools, care pathways, etc.  Any readers interested in this subject area are encouraged to attend and/or share the link with their colleagues. The program link for registration, etc. is below.

http://hcmarketplace.com/avoidable-rehospitalizations

 

September 28, 2016 Posted by | Skilled Nursing | , , , , , , , , | Leave a comment

CMS Proposes Additional Bundled Payments: The Post-Acute Implications

On July 25, CMS released a proposed rule to create additional bundled payments/DRG focused EPMs, targeted for July 1, 2017.  The announcement/proposed rule is consistent with CMS’ and the Administration’s goal to migrate up to 50% of all traditional FFS (fee-for-service) payments to alternative models by 2018.  As with the CJR (bundled payments for hip and knee replacements), the comment period is relatively short.  Similarly, the likelihood of CMS deviating much in terms of timelines and methodology (payment) from the proposed rule is slim.  The view is that CMS has foretold providers of these initiatives, created a pathway or road map via analogous alternative models (BPIC and ACOs), and developed a systematic approach to the operational elements of the initiatives sufficient for providers to adapt and move forward.

Bundled Payments for Coordinated Cardiac and Hip-Fracture Care

As in the CJR initiative/rule, CMS has identified certain DRGs that it believes via evidence and study,  present opportunities for cost reduction and improved quality outcomes emanating from initial hospitalization through an episode of care equaling 90 days.  Following a near identical road map or path used with CJR (hip and knee replacement), CMS will provide the originating hospital with a target payment goal based on a regionally weighted average  with a small, statistically smoothed reduction.  This targeted value is the cost benchmark for the applicable DRG plus all related costs for a period totaling 90 days, encompassing the hospital originating stay.  Functionally, the payment equals the hospital inpatient stay, post-acute services, outpatient services, certain physician and supply components, etc. (aka the Episode Payment or “bundled payment”).  Below is a summary of the DRGs that make up the new “bundles” and the methodology in terms of how this initiative is set to work.

  • Includes cardiac care elements/DRGs for myocardial infarction and coronary artery bypass graft procedures (MI and CABG) plus an orthopedic element for hip/femur fractures and surgeries that is an addition or augment to the CJR.  The cardiac elements are mandated for hospitals in 98 MSAs (anyone who wants the list or wants to know about a particular region, contact me as provided on this site).  The hip/femur element is only applicable in the CJR regions; the original 67.
  • The related DRGs are:
    • Myocardial Infarction (MI): DRGs 280-282
    • Coronary Artery Bypass (CABG): DRGs 231-236
    • Surgical Hip Femur Fracture Treatment (SHFFT): DRGs 480-482
  • The Hospital is paid a calculated amount based on a regional target by applicable DRG
  • The amount is equal to the cost of the care at the hospital and the target, reflects the total expected cost for the complete episode of care (hospital, physician, post-acute).  The actual payment to the hospital is the target amount minus a quality measures discount equal to 1.5 to 3%.  Based on actual performance, savings can be returned as an incentive or recouped.
  • Post-acute providers bill per fee schedule.
  • In year 1, CMS reviews the costs per episode, the applicable quality indicators and patient satisfaction results. The review is against expected costs and quality standards.
  • In year 2, CMS reviews the same data and if the costs and quality are equal to or better than expected, the hospital can receive an incentive payment. If worse, the hospital will see a payment reduction (capped at 5% in year 2, moves to 10% in year 3 and 20% in following years).
  • Hospitals after year 1, can contract with post-acute providers to share risk (gains and losses) if the post-acute providers meet certain quality standards (3 star or better).
  • The whole initiative is slated for a 5 year period after which, CMS will review.

(The above is a cliff-note version covering the major highlights.  I have a client-based, in-depth summary that I can provide to readers.  Contact me via email at hislop3@msn.com or via a comment to this post.  Please provide a current, working email address and I will forward the summary, free of charge)

Within the proposed rule, CMS introduced two additional initiatives;

  • Cardiac Rehab Incentive Payments: A series of incentive payments to get hospitals under the Cardiac initiative to aggressively push patients into cardiac rehab programs during the 90 day Episode. These payments would be made to participants in 45 regions not selected and 45 additional regions selected within the bundled payment program.
    • First 11 cardiac rehab services will include a $25 per service bonus.
    • Services after 11 will include an incentive payment of $175 per service, up through the 90 day episode window.
    • Sessions are limited to 36 one hour periods over 36 weeks with a possible extension of an additional 36 sessions over a longer period if authorized by the MAC (Medicare Administrative Contractor). Intensive sessions are limited to 72 one hour sessions, up to 6 sessions per day, for 18 weeks.
  • A pathway for physicians that participate in bundled payments to qualify for financial rewards under the Quality Payment Program (CHIP and MACRA). Essentially, the methodology creates incentives for physicians that choose to be at a certain level of financial risk for payment loss, to gain incentive payments for meeting certain quality standards and adopting Electronic Health Record Technology.

Post-Acute Implications and Strategies

Unlike CJR, the implications for post-acute providers under the cardiac components are fairly minimal. The typical down-stream referrals (post-acute hospitalization services) for the cardiac components in the rule are minimal.  Most cardiac patients utilize after-care services through the hospital directly; principally for cardiac rehab.  When post-hospitalization discharges include care services, the bulk are through and coordinated with home health.  If more intense periods of inpatient care are required after acute hospitalization, the typical path is discharge to LTAcH or IRF.  This component however, can provide some strategic opportunities for SNFs that want to embrace a cardiac program with proper staffing, technology investments (telemetry), etc.

The SHHFT (hip/femur fracture) initiative is similar in opportunity to the CJR.  It presents SNFs and HHAs with numerous opportunities to partner with orthopedic groups, hospitals, and surgery centers to develop lower cost, high quality, coordinated care programs.  As with CJR, this phase of the bundled payment programs includes regulatory waivers for high quality providers (start ratings 3 and above).  These waivers include the three-day qualifying hospital stay for SNF coverage and the relaxation (requirements) of direct referral relationships that include incentive dollars.

For certain post-acute providers, there may be some opportunity to advance into the cardiac rehab arena.  While the incentive payments are targeted to the hospital, the hospital can pass these along and many may want do to just that.  Hospital cost structures are often too high to reap a modest incentive reward such as provided in the rule, necessitating a partner-type relationship to deliver the actual programming.

Strategically, post-acute providers need to consider the following and position accordingly;

  • As with CJR, star ratings matter.  SNFs and HHAs that want to succeed, garner partner opportunities and referrals should rate/rank 4 or 5 stars.  While three stars can play, the same will be market constricted by the 4 and 5 star programs.
  • Quality matters.  Post-acute providers need to aggressively monitor their outcomes and their patient satisfaction.  I recommend the following at a minimum.
    • QA and reduce as much as possible, any rehospitalization.  To do this, staff need training, tools such as INTERACT, service depth expanded and reviewed, and proper support tools and equipment available.
    • Employ or develop a Care Navigator within your organization (more than one if need be).  I recommend that this position is tasked with handling all critical elements of the initial referral and intake, coordinating all care during the post-acute stay, coordinating discharge including referrals downstream (e.g., SNF to home care), coordinating return physician visits, patient teaching, and all follow-ups on status and questions.  This role should include watching lengths of stay and gathering critical quality measures such as weight loss, wound/skin, falls, infections, etc.
    • Develop and utilize pathways and protocols that correlate to the bundled payment DRGs for the post-acute components.  In other words, if your organization is a SNF, it should have a post-surgical pathway for a femur fracture that covers from admission, pain management, therapies, skin and wound, length of stay, patient teaching, discharge, etc. all laid out in a pathway/decision matrix married to care plans.  Not only are these necessary to assure effective, efficient care; they are great marketing tools.  Collaborate with the hospital, with physician partners and discharge partners to gain a complete perspective.
    • Train and develop staff skills to coincide with the types of patients encompassed by the bundled payment models.  Your SNF or HHA should have expertise in every care element plus ideally, staff that have advanced training and certifications in key disciplines.  For example, an SNF that seeks to take post CABG patients needs RNs with ALS certification and telemetry experience/training.
    • Develop a post-acute continuum.  Playing in the bundled payment arena now and going forward as a post-acute provider will necessitate having a continuum of services.  Bundled payments and being at risk are anathema to truncated, one-off providers.  In other words, an SNF that doesn’t have a HHA component and outpatient component won’t be a referral magnet as the EPMs (episodic payment models) move forward.  I recommend providers that can, acquire or develop their own programs and those that cannot, partner accordingly.  Quality and efficiency are key so if for example an SNF chooses to partner with a HHA, the SNF is warned to find such an agency that will match quality, monitor all elements of outcome data and satisfaction, collaborate on program development, QA, etc.  The same is true for outpatient relationships.

As with CJR, the focus in this next phase is to re-shape how the post-acute provider world interacts with the acute hospital and physician world.  Providers need to re-organize thematically on quality, efficiency and collaboration. The winners (if you will) are the providers that manage the most services, in a coordinate delivery model, that can demonstrate quality with the ability to manage and coordinate care across a myriad of delivery points; seamlessly.

 

August 5, 2016 Posted by | Home Health, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , | Leave a comment

The Supreme Court, False Claims Act, and Implications for Providers

Nearing the end of the Supreme Court session, the Court issued an important clarification ruling concerning the False Claims Act in cases of alleged fraud.  In the Universal Health Services case, the Court addressed the issue of whether a claim could be determined as fraudulent if the underlying cause for fraud was a lack of professional certification or licensing of a provider that rendered care related to the subsequent bill for services.  In the Universal case, the provider submitted claims to Medicaid and received payment for services.  The services as coded and billed implied that the care was provided by a licensed and/or qualified professional when in fact, the care was provided by persons not properly qualified.  In this case, the patient ultimately suffered harm and death, due to the negligent care.

The False Claims Act statute imposes liability on anyone who “(a) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; or (b) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim.” It defines “material” as “having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.” And it defines “knowingly” as “actual knowledge; … deliberate ignorance; … or reckless disregard of the truth or falsity of the information; and … no proof of specific intent to defraud is required.” The last element is key – no proof of intent to defraud is required.

Though providers sought a different outcome, the initial review suggests the decision is not all that bold or inconsistent with other analogous applications.  The provider community hope was that the Court would draw a line in terms of the expanse or breadth of False Claims Act “potential” liabilities.  The line sought was on the technical issue of “implied certification”; the notion that a claim for services ‘customarily’ provided by a professional of certain qualifications under a certain level of supervision doesn’t constitute fraud when the services are provided by someone of lesser professional stature or without customary supervision, assuming the care was in all other ways, properly provided.  The decision reinforces a narrow but common interpretation of the False Claims Act: An action that would constitute a violation of a federal condition of participation within a program creating a condition where the service provided is not compliant creates a violation if the service was billed to Medicare or Medicaid. Providers are expected to know at all times, the level of professional qualifications and supervision required under the applicable Conditions of Participation.

The implications for providers as a result of this decision are many.  The Court concretized the breadth of application of the False Claims Act maintaining an expansive view that any service billed to Medicare and/or Medicaid must be professionally relevant, consistent with common and known professional standards, within the purview of the licensed provider, and properly structured and supervised as required by the applicable Conditions of Participation.  Below are a few select operational reminders and strategies for providers in light of the Court’s decision and as proven best-practices to mitigate False Claims Act pitfalls.

  • One of the largest risk areas involves sub-contractors providing services under the umbrella and auspices of a provider whereby, the provider is submitting Medicaid or Medicare claims.  In these instances the provider that is using contractors must vet each contractor via proper credentialing and then, provide appropriate and adequate supervision of the services.  For example, in SNFs that use therapy contractors the SNF must assure that each staff member is properly licensed (as applicable), trained to provide the care required, and the services SUPERVISED by the SNF.  Supervision means actually reviewed for professional standards, provided as required by law (conditions of participation), properly documented, and properly billed.  The SNF cannot leave the supervision aspect solely to the therapy contractor.
  • Providers must routinely audit the services provided, independently and in a structured program.  Audits include an actual review of the documentation for care provided against the claim submitted, observations of care provided, and interviews/surveys of patients and/or significant others with respect to care and treatment and satisfaction.
  • Establish a communication vehicle or vehicles that elicits reactions to suspicious activity or inadequate care.  I recommend a series of feedback tools such as surveys, focus groups, hotlines and random calls to patients and staff.  The intent is to provide multiple opportunities for individuals, patients, families and staff to provide information regarding potential break-downs in care or regarding outright instances of fraud.
  • Conduct staff training on orientation and periodically, particularly at the professional level and supervisory level.  The training should cover organizational policy, the legal and regulatory framework that the organization operates within, and case examples to illustrate violations plus remedy steps.

July 24, 2016 Posted by | Home Health, Hospice, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , , , | Leave a comment

SNFs: Strategies to Mitigate Readmission and Rehospitalization Risk

Across a number of regulatory elements beginning this year (May/June through October), hospitalization and readmission rates (to) post-hospitalization from SNFs will be measured and ultimately, factored into the SNF landscape via reimbursement penalties and Star ratings.  Below is a quick summary of where and when the hospitalization/readmission issues come into play.

  • CJR – aka bundled payments for Hip and Knee replacement, began April 1.  The issue here is that readmissions post-hospital discharge count against the required measurement elements of cost and quality across the 90 day episode of care.  The impact is direct to the discharging hospital but in turn, can impact the willingness of hospitals to discharge to an SNF if the readmission risk is outside the regional quality benchmarks.  Poor performance can impact referrals, go forward partnerships and for those SNFs that can and will participate at-risk in Year 2, access to incentive payments.
  • SNF VBP Value Based Purchasing begins in July of this year with the first measurement period continuing through July of 2017.  Rehospitalization rates for SNFs will be measured (all cause, risk adjusted).  Beginning in October 2018, CMS will reduce Medicare A payments by 2% for SNFs that perform on this measure, below benchmark standards.
  • Five Star – in May/June of this year, new measures are added including rehospitalizations (plus hypnotic use, discharge home, decline in ADL status since admission, mobility in room).  The QMs will be rebased to incorporate these new measures.
  • IMPACT Act – Expected in the SNF PPS final rule for 2016 (April, data collection beginning in October 2017) are four new measures including rehospitalization upon admission and 30 days post discharge from the SNF.  The other elements are discharge to community, drug regimen review and average cost per beneficiary during and after the SNF stay.

Though I have cautioned facilities to pay attention to their hospitalizations/rehospitaliztions for some time now, it isn’t too late (almost) to get started; started in earnest!  Below are my top four recommended strategies to employ ASAP (not in any particular order) to mitigate post-discharge hospitalization risk and post-admission rehospitalization risk.

  1. QA Your Transitions: Every hospitalization/rehospitalization requires a QA analysis of the reasons why, whether such reasons were appropriate/inappropriate, what transpired at the hospital, and most important, what could be done (if anything) to change the events leading to the transition.  The latter element is part of the organization’s QAPI and begets staff training, system change, etc.  The key is to do a true root cause analysis.
  2. Staff Education: As my firm works with facilities constantly, we notice that the largest, single reason for care transitions out of the SNF to the hospital (ER, etc.) is a lack of staff competence in assessment and communication with physicians and families.  The inability to present a clear picture of the resident’s current condition, options, monitoring points, etc. creates confusion for the physician and a sense of insecurity for family, precipitating the transition if for no other reason than perceived “safety”. Plenty of tools exist (contact me for resources) from AMDA (physician communication protocols) to INTERACT.
  3. Advance Care Planning: Too often this subject is viewed as gathering advance directives (code/no code status, Living Wills, DPOaHCs, etc.).  While these are important the real crux or guts of this element is the discussion concerning specificity of care decisions, including hospitalization/care transitions.  Based on my and my firm’s experience, better than half of all care transitions to a hospital are avoidable with proper planning.  Up front, clear conversation with patients/residents and families regarding the SNF resources (what can be done in-house, etc.) and the risks of hospitalization can and will reduce hospital transitions (particularly ER visits).  I suggest developing a communication tool regarding the decision(s) and sharing it with staff, physicians and most important, patients and families.
  4. Algorithms and Pathways: These elements take the vagaries out of the care planning and care delivery process, eliminating what can be and typically  are, transition triggers.  For CJR, we built hip and knee pathways.  These translate to standardized careplans, address the advance care planning elements, discharge points, pain, skin/wound, etc. comorbidities.  As these elements are addressed pre-admission and within 24/48 hours of admission, a clear reduction in transition risk is present.  Likewise, build as many comorbidity (common) algorithms as possible. For example, I recommend pain, anti-coagulation, diabetes, CHF, depression, and bowel/constipation protocols as a start.  Depending on the SNF’s admission profile (typical case-mix), others may be more pertinent.  What we know is that too many transitions occur as a result of an unclear game plan and approach to resident/patient care leaving careplanning gaps, communication gaps, and treatment protocol gaps.

Concluding: A few caveats apply.  Reducing readmission and/or rehospitalization risk starts at a core facility/organization level.  My strategies above assume that the SNF has proper/adequate staff levels and adequate resources in terms of a solid therapy program, medical direction and physician staff.  Additionally, the SNF should have (by now) a functioning QAPI program in place.  Without such a program, the core QA function required to understand transitions and complete a root cause analysis is only an exercise.  Finally, one last tip.  Reducing hospitalizations/rehospitalizations is an organization-wide initiative.  It is not solely a nursing or social services function.  Every discipline has a role and when the root causes of transitions are analyzed it becomes clear quickly, how many little or seemingly minor pieces properly detected and addressed, contribute to reducing this risk element.

April 12, 2016 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , | 2 Comments

Bundled Payment Primer: SNFs

On April 1,  implementation of the CMS expanded Bundled Payments for Care Improvement demonstration for hip and knee replacement (aka CCJR) begins.  This phase takes the initial voluntary BPCI program and expands the concept on a non-voluntary basis to 67 metropolitan regions.  See my post on the final rule here at http://wp.me/ptUlY-jh.  Effectively,  Medicare reimbursed knee and hip joint replacements through a covered (Medicare) center (hospital or qualifying surgery center) within one of the designated regions, will be paid on a “bundled” basis.

Overview

Beginning April 1, 2016 (and for five consecutive years) CMS will establish a target price for each designated region for each episode (hip or knee) of care. This target price is then discounted by 2% and operates as a benchmark – the bundled payment amount.  For any Medicare hip or knee replacement surgery at the qualifying hospital, the payment is designed to reflect the costs of the admission, surgery, hospital services, and all additional post-acute costs of care for 90 days following the surgery. All providers, including the hospital and suppliers, bill Medicare for care provided (Parts A and B as applicable) on a fee-for-service basis.  CMS then aggregates the payments made via Medicare for the referenced element of care and all other related (hip and knee) elements across a performance year and compares the same to the regional target.  If costs incurred are equal to or lower than the target (bundled payment benchmark) and the hospital met or exceeded certain quality measures, a bonus or reconciliation payment is made (payment is the difference between the actual costs and the benchmark, up to a specified cap) to the hospital.  In year one, no penalty is applied for costs above the benchmark or lesser levels of quality.  In year two however, less than targeted cost or quality outcomes will create a payment recoup scenario equal to the cost difference compared to the benchmark, up to a certain cap.

Implications for SNFs

For SNFs, while there is no direct correlation in Medicare payments per the bundled payment initiative (no bonus applicability, penalty, etc.), the indirect implications are enormous and potentially for many, survival (or not) deep.  Consider the following;

  • While the hospital is accountable directly for costs and quality, the cost benchmark covers all care costs within the element of care, including the SNF post-acute stay.  An expensive, inefficient stay imputes higher costs into the “total cost” equation.
  • While the hospital is directly accountable for the quality measures, the quality measures cross domains.  Poor quality, readmissions, low patient satisfaction affects the over quality measures and can lead to payment reductions after year one.   The quality measures are;
    • Complication rates post procedure
    • Readmissions within 30 days
    • Patient satisfaction of providers across the element of care
  • After year one, only SNFs (that) rated three stars or above can participate in the program. Hospitals can only refer to 3 star or higher ranked providers.

Taking into account the three points above, SNFs can and will experience, game changing referral and relationship dynamics within the affected regions.  Hospitals will seek (and have sought) relationships with  high quality, cost-effective post-acute providers.  For example, one hospital system that I advise regularly has drawn a clear line for referrals at 4 stars and preferably, 5 stars – one year ahead of the requirement.  They have already shifted their referral practices in anticipation.  Further, as the Final Rule created opportunities (regulatory laxity) and freedom for incentive sharing, alliances are forming whereby providers will share incentives in order to assure high quality, cost-effective outcomes.

Strategies for SNFs in a Bundled Payment Region

While April 1 looms, there is still time for an SNF to get properly positioned initially, for a bundled payment transition.  Why I say initially is that most providers, including hospitals, will not be fully ready (and CMS is still providing additional details) for the “new” reality.  As with all programs of this nature, a great deal is learned as lived as regulatory details dribble past deadlines and frankly, many providers simply won’t have systems in-place, fully integrated to monitor the costs, quality measures, etc. across all domains.  Further, year two is where the game really changes as penalties apply in addition to bonus opportunities and the three star limit becomes effective.

Below is my outline or roadmap that SNFs should follow to succeed and thrive in a bundled payment environment.  Note: CMS will push forward, additional elements of care, beyond hips and knees, with bundled payments.  Likewise, regions will expand and targeted regulations (separate from bundled payments) for SNFs impute quality measure impacts on payments (commencing in October 2016). Simply stated: the following has broader implications than just bundled payment implications.

  • Manage Your Stars: Simple but difficult for many.  If your facility is not four stars or above, you will have trouble and will see a reduction in Medicare census and referrals.  Even three stars is and will be, inadequate.  This is especially true in a market where there are competing facilities at the three or better (star) level.  Changing your star rating is not an overnight process but the best start is to drill hard on your quality measures (improve) and survey results.  Staffing numbers can shift quickly but only by integrating more professional nurses at the bed side, without reductions in per patient day staff ratios (a financial investment).  Remember, with PBJ forthcoming, the numbers can’t be “phantom” staff (sorry but too many SNFs today have jacked up their star levels by gaming the self-reported staffing system).
  • QA Your Care Transitions: No SNF should today, fail to intimately manage their care transitions – all transitions.  Readmissions are a risk area in bundled payments and today, for SNFs regardless (readmission penalties apply for 2016).  Similarly, one of the simplest ways to manage costs related to any stay is to insure that the maximum level of care is available on-site and the resident doesn’t need to transition for things like wound management, radiology, other diagnostics, physician visits, etc.  The cost of the transport if attended and billable, the costs associated with the encounter, the diagnostic, etc. all “count” in the analysis of the cost of care per element against the bundled benchmark.  In addition, risk is inherent in any transition for a resident/patient.  Everything from infection to fall risk heightens when a resident/patient is transported out of the environment and then back.
  • Excel at Advanced Care Planning and Discharge Planning: From the hospital encounter through the SNF stay and beyond, keeping the stay efficient and the resident/patient satisfied is all about care planning and discharge planning.  The rule of thumb is the earlier the better.  If possible, assign a Care Coordinator to the encounter, early – ideally concurrent with the hospital admission.  Discuss the options with family, the patient, the team and build as much into the discharge plan as early as possible.  For example, if “home” is the goal, get into the patient’s home as early as permissible. If there is family involved, start teaching and providing resources as soon as possible.  If post SNF care is required, connect as much of it (e.g., home health) as early as possible and get the other provider elements into the equation ASAP.
  • Use an Algorithm or Pathway: Build a hip and knee protocol, pathway/algorithm that covers all elements (typical) of therapy by day by type of surgery.  Inclusive should include radiology protocols, pain, wound care, supplies, safety precautions, etc.  Work this protocol through your QAPI process with your physicians/Medical Director.  Ideally, get hospital folks to react and help and add input, especially Orthopods (if they will participate).  I recommend incorporation of pharmacy, nutrition, nursing, and social service as integral elements, especially as the same relate to co-morbidities or post-surgical management.  For example, having pharmacy manage and coordinate your anti-coagulation protocol.  The more you can develop a “recipe” for folks to follow and measure, the greater the likelihood of a smooth transition, exceptional outcomes, and enhanced patient satisfaction.
  • Manage and Align Your Partners: Understanding that risk comes from multiple elements is key to achieving high quality and superior efficiency.  Many SNFs use contractors for care elements such as therapy and pharmacy, physician services, etc.  Every discipline that is part of the care process must be aligned to assure high quality and efficient care.  This environment (bundling) is different now.  Its not about “more” care as many have become accustomed via Medicare RUG maximization and extending lengths of stay.  It is about the right care.  Physicians need to help; keep orders simple, reduced redundancy and unnecessary tests, etc.  Pharmacy needs to do medication reconciliation at admission and actually, somewhat virtually.  Formularies must be tight to assure the most targeted, effective, and lowest cost medication regime.  If home health is part of the discharge process, pick a single partner or limited partners and integrate them into the process.  Remember, the risk areas encompass satisfaction and cost elements across a 90 day horizon!
  • Build Your Core Competency: Delivering high quality, cost-effective care is about having exceptionally competent, well-trained staff giving the care, supported by focused, competent management.  Nurses must be capable of caring  for the patient profile from wound to pain to skin to all other components.  All staff must be responsive and focused on issues like fall risk, weight loss, dehydration, infection, etc.  These issues are monitored daily and part of, what should be, an integrated QAPI program.  Social Workers must be able to field questions, coordinate resources, and be responsive, informative and knowledgeable about resource issues (Medicare, insurances, etc.).  Review all aspects of care and look to bring them into the environment if feasible.  For example, invest in anti-coagulation machines, products to float heels (Heelzup), proper size wheelchairs, patient lifts, air mattresses, etc.  I commonly recommend having at least some staff wound care certified, pain management certified, cardiac certified, etc.  I like to have therapists with advanced training in neuro, lymphedema care, sports medicine (great for ortho rehab), etc.  Without the resources in-house, it is very unlikely that an SNF will be able to manage the current and go-forward demands of lower cost and higher quality.

February 5, 2016 Posted by | Skilled Nursing | , , , , , , , , | Leave a comment

Bundled Payments: Final Hip and Knee Rule

On November 16, CMS issued the final rule for bundled payment demonstration, lower extremity, effective April 1, 2016.  A single payment, made to a qualifying hospital in one of 67 regions/MSAs covers all aspects of the hospital care, the surgery, and any post-discharge, post-acute stay components through 90 days (from initial hospitalization). The payment exclusions include unrelated hospital and Part B costs, unrelated acute and chronic DRGs and drugs outside the episode (clotting factors, etc.).  The original proposal known as CCJR (Comprehensive Care for Joint Replacement) included 75 regions/MSAs.  The final rule whittled the total to 67 excluding regions such as Colorado Springs, Richmond, VA and Las Vegas.

The CJR (eliminate “care”) is the adjunct or next logical progression from the BPCI (Bundled Payment for Care Improvement) project. The BPCI is voluntary.  CMS has foretold policy watchers and providers that this initiative was forthcoming and while comments to the  proposed rule were deep, CMS was determined to move forward.  The sole major concession was a 3 month delay in implementation (April 1 v. January 1).  Among the concerns expressed were;

  • Impact likelihood on home care (negative) as the home health value based purchasing model comes on-line January 2016.  Concern across the industry about adjustment and preparation time given that the two program implementation dates are fundamentally, side-by-side.
  • Lack of preparation time and specifics in the final rule regarding payment.
  • Lack of fraud and abuse clarifications in the rule.  CMS has acknowledged a need to publish guidance and waivers for providers, specifically around physician self-referral and kickbacks (incentives shared between participating Medicare providers in a coordinated care program violate Medicare anti-kickback provisions on a prima facie basis). CMS has provided waivers before to facilitate ACO operation and formation.

The core of the  demonstration program is to clearly, create a model for shared risk and shared savings between providers, targeted at common care events that span acute and post-acute stays/utilization. The fee for service average for hospitalization and recovery ranges from $16,000 to $33,000 (excluding medical/physician care). CMS is targeting $343 million in savings over the 5 year program life.

In order to achieve the targeted savings, the program has some unique twists or elements that are different from the typical fee-for-service model.

  • The three-day/three inpatient overnight rule for coverage in a post-acute environment is waived.  Patients can be admitted or not, surgery performed, and discharged as care and conditions warrant.
  • For SNFs to participate, their star ratings must be no less than 3 stars on the CMS Compare website.  This is already an issue in certain markets where few facilities meet the criteria.
  • The target price for an episode is a blend of historical and regional pricing, discounted by 2%.  If the actual spend is less than the target price, a reconciliation or incentive payment is due PROVIDED, the hospital has met or exceeded (30th percentile nationally in years 1-3, 40th percentile thereafter) the HCAHPS (patient satisfaction measures), hip and knee readmissions and hip and knee complications measures. Any over-spend or failure to meet quality measures equals no reconciliation payment.  Reconciliation payments are effectively the recoup (partial) of the imputed discount to the target price.

The takeaway for post-acute providers is simple, especially as it relates to the thematic shift this demonstration project is foreshadowing: get lean, get good, and get partners. I wrote about the “new era” a few months ago on this site: http://wp.me/ptUlY-iE .  The fee-for-service trend and the Medicare maximization game (highest RUG, longest stay, etc.) is ending.  I have lectured and written for years before this rule was ever finalized that quality is the number one element that SNFs and HHAs must understand, embrace and demonstrate if they wish to thrive and survive.  The CJR demonstrates it via the “star rating” requirement for SNFs. Facilities that haven’t paid attention, are not up to par, will risk being left out.  Improving your star rating is not quick nor is there a gimmick to employ to change the rating or an appeal process available.

In a soon to follow post, I will address the go-forward implications and strategies for post-acute providers, principally SNFs and HHAs, with respect to the CJR.

 

 

December 1, 2015 Posted by | Home Health, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , | Leave a comment

Core Administrative Competency: SNF

As I have written before and readers know, I field as many questions and provide as many resources as I can “free” of charge.  My e-mail is publicly available for contact on this site and on my LinkedIn page.  The title of this post thus, is a reference to the many questions I’ve received as of late regarding a number of issues ranging from fraud, to Medicare, to managed care, to therapy contracts, to quality.  Core Administrative Competency is about what truly, folks in senior administrative positions need to know/develop in order to be more effective in their role(s).

  1. Know How and Why You Get Paid: Sounds fundamental but I have so many conversations with folks that just simply don’t know this subject area very well.  I’m not talking at a technical level like being an MDS expert but at a core level – core enough to understand the relationship between the case-mix, the payment, the RUGs, and to ask clear questions regarding RUG distributions, etc. How about Part B?  Do you know the cap?  Do you know the authorization requirements for cap exceptions? The same is true if your facility takes managed care patients.  Is the payment based on RUGs, levels, other negotiated rate?
  2. Know What you Make from What you Get Paid: Again, sounds fundamental but this one I often find sorely lacking.  The RUG isn’t what the facility makes. The payment either from managed care or Part B.  How about Medicaid?  I have had way too many discussions with SNF administrators and even finance and billing folks where they didn’t realize that they were getting creamed by the insurer and their therapy contractor.  The therapy contract facilities tend to be the most out of line.  The facility is paying the therapy contractor per increment rates – flat for service per the contract.  The facility is receiving then a RUG, a level payment, payment under Part B, etc. Sometimes, the difference between what the facility is receiving via payment and what it is paying out to the therapy contractor for the therapy component, nets the facility zero or less in terms of margin.  This is particularly true with managed care agreements, unless the facility has negotiated variable rates reflective of the payer source.  The same can be true with drugs, medical supplies, etc.  I don’t know how many facilities I have worked with that fail to negotiate “carve-outs” within their managed care agreements for high cost DME (special beds, etc.), certain types of drugs (some antibiotics for example), and wound care supplies.  These elements alone, with RUG based or  level payments, can quickly create losses at the facility level.
  3. Know Your Quality Indicators and Measures: Battling fraud, survey/compliance risk, litigation risk, etc. boils down to knowing your quality and how it stacks up against the industry.  Likewise, these measures are core principles in the upcoming ACO, bundled payment, managed risk environment.  Administrators and DONs should be intimately familiar with and checking on, core quality measures such as infections, falls, hospitalizations, call light wait times, medication and treatment errors, etc.  One of the largest fraud risk areas for any SNF today is over-billing or improperly billing Medicare.  This occurs when the care is substandard or inappropriate for the resident’s needs/condition.  Knowing your quality, being engaged in the QI process is critical to risk prevention and management.
  4. Know Your Contracts for Service: Again, sounds fundamental but all too many administrators that I talk with have never really read their therapy contract.  No wonder they are surprised when they see charges for say, $75 per hour for meeting attendance – at a Care Plan meeting! How about the limitations of liability clauses?  Payments?  QA participation requirements, audit elements, staff retention terms, etc.?  Same is true for pharmacy.  What are the consulting costs and provisions?  What about drug costs?  How are drugs dispensed and in what supply?  Liability for medication errors?  What are the limitations?  Now, extend the same logic to food, other vendors, etc.
  5. MBWA: The goal of all facility administrative staff is to emphasize time spent doing this – known as Management By Walking Around.  The job of an administrator, DON, etc. is not in the office but on the floor, in the meetings at the care level, engaged with patients, physicians, families, and the community. The best prioritize their days around time out of the office.  I often ask administrators how many careplan meetings they sit in, staff education sessions, stand-up meetings, QA, staff meetings, departmental meetings, etc.  I am amazed at the answer (how little).  I am equally amazed and perhaps more, at how few tell me they ever meet with their key hospital referral sources at their peer level.
  6. Know the Industry: The industry is changing rapidly in terms of policy and trends.  Perhaps the largest leadership failure I see “routinely” is administrative personnel (administrators and DONs) that don’t stay current and don’t seek best practices.  Sure, they may attend a trade association conference from time to time, but read, study or explore beyond – rarely.  To be really effective requires being as far ahead as possible; to see the trends and understand the policy, reimbursement, and best practice landscape.  Doing so affords the ability to do gap analysis – where are we vs. where do we need to go.  Doing good gap analysis thus allows development of plans and strategies for improvement.  The biggest risk is getting caught off-guard, behind the times.  For example, being an SNF today with a rehab contract and no plans in place to audit your contractor.  I’ve described “why” and the fraud trends that are rampant on this site.

June 5, 2015 Posted by | Skilled Nursing | , , , , , , , | Leave a comment

Medicare, Billing Audits and Self-Disclosure

Over the last six months or so, I’ve written a number of articles on the issue of SNFs, therapy contracts/contractors, and recent fraud settlements. I’ve also given a few presentations on the same subject, covering how fraud occurs, the relationships between therapy contractors, SNFs and Medicare, and the keys to avoiding fraud. A reader question based on this subject area is the genesis (the answer is anyway) of this post.  The questioned shortened and paraphrased is;

“If we (the SNF) conduct an audit of our therapy contractor and our Medicare claims as you suggest and we find abnormalities that appear to be fraudulent claims, what do we do next?  We know we have to correct the practices that allowed the claims to happen but is there something else we need to do?”

Not only is this an excellent question given the subject area, the answer or outcome is likely the reason so many providers don’t or won’t audit their therapy contractors and Medicare claims (afraid of what they might find). The answer to the question is YES, there is something else to do and it is a federal requirement if a provider wishes to potentially avoid Civil Monetary Penalties and other remedies.  This key step is known as Self Disclosure.

Starting at the beginning: If the results of the “audit” determine that Medicare was billed inappropriately, the provider is in potential violation of the False Claims Act.  The False Claims Act describes violations as ‘any entity or person that causes the federal government to make payments for goods or services that are a) not provided b) provided contrary to federal standards or law or, c) provided at a level or quality different than what the claim was submitted for (summarized)’. For Medicare, providers are in violation of the False Claims Act if bills are/were submitted to Medicare (and paid) for care that was inappropriate, unnecessary, falsely misrepresented (upcoding, documentation etc.) or not provided.  Assuming, as the questioner poses, that the audit found abnormalities (improper bills and payments) to Medicare (Parts A, B, or C) for any of these reasons, a False Claims Act violation (liability) has been identified.  The provider has obligations as a result, under federal law.

The “obligation” once the activity is discovered is to self report.  The OIG maintains a Self Disclosure Protocol policy that can be accessed here ( http://oig.hhs.gov/compliance/self-disclosure-info/files/Provider-Self-Disclosure-Protocol.pdf ). Self Disclosure is a methodology that providers can use to potentially avoid Civil Monetary Damages, other remedies and extensive legal costs. Self Disclosure however, cannot be used to mitigate criminal penalties if the activity that is part of the Medicare False Claims violation was/is criminal.  Self Disclosure also is not relevant for overpayments.  Overpayment issues are handled via the Fiscal Intermediary directly.

Per the OIG Self Disclosure Protocol:

“In 1998, the Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS) published the Provider Self-Disclosure Protocol (the SDP) at 63 Fed Reg. 58399 (October 30, 1998) to establish a process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud involving the Federal health care programs (as defined in section 1128B(f) of the Social Security Act (the Act), 42 U.S.C. 1320a–7b(f)). The SDP provides guidance on how to investigate this conduct, quantify damages, and report the conduct to OIG to resolve the provider’s liability under OIG’s civil monetary penalty (CMP) authorities.”

Below are some key points providers need to know prior to and in connection with, a self disclosure process.  Again, I encourage all providers that are conducting a billing audit or considering a billing audit, to access the PDF from this post and review the OIG Self Disclosure Protocol.

  • A current regulatory process or audit from Medicare (or a contractor such as a ZPIC audit) does not mean that the provider cannot self disclose, provided the disclosure is in good faith.
  • Further investigations and reviews are part of the process and providers need to be aware that the OIG will direct the provider’s investigative process as part of the self disclosure.  In other words, the audit the provider conducted which may have identified the false claims is not the end nor will it suffice to resolve the matter once disclosed.
  • Providers that wish to self disclose need legal counsel as the initial disclosure requires a succinct identification of the legal violations applicable and the scope of the activity and dollar amounts (potential) involved.
  • Self disclosure should only be made after corrective action has occurred.  The disclosure does not suffice as a remedy for conduct going forward nor can it absolve liability in scope that predates the disclosure or the period disclosed (see the point prior).
  • Providers need to be aware that this process is not quick nor does it alleviate or mitigate any requirement for repayment of improper claims. Additionally, providers need to recognize that resolution will require mitigation steps including potential agreement to a compliance program/plan and commitment to additional monitoring/auditing, depending on the scope of the violations disclosed.

I encourage providers to read the Protocol and to pay particular attention to 5 – 9. While I know the information may seem daunting and discouraging, don’t use this post or the information in the Protocol as a reason to not conduct a Medicare billing/claims audit and/or to not report, if violations are found.  I assure you, having worked extensively with providers caught by the OIG, DOJ and/or in a Qui Tam action, prevention and self disclosure, while onerous is far better and cheaper than what occurs if the violations are discovered federally.

 

April 10, 2015 Posted by | Home Health, Hospice, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , , , | 2 Comments