CMS pulls the RUGs out from under Providers Potential Effects of SNF PPS Final Rule

Transcription

1 CMS pulls the RUGs ut frm under Prviders Ptential Effects f SNF PPS Final Rule

2 T Receive CPE Credit Participate in entire webinar Answer plls when they are prvided If viewing this webinar in grup Cmplete grup attendance frm with Title & date f live webinar Yur cmpany name Yur printed name, signature & address All grup attendance sheets must be submitted t Training@bkd.cm within 24 hurs f live webinar Answer plls when they are prvided If all eligibility requirements are met, each participant will be ed their CPE certificates within 15 business days f live webinar 2

3 SNF PPS Final Rule FY2012 Published in August 8, 2011, Federal Register Effective Octber 1, 2011 Applies t SNFs, hspital-based SNUs, & swing beds (except in CAHs) 3

4 Plling Questin Are yu affiliated with free-standing SNF r hspitalbased? SNF Hspital-based SNU r swing bed Neither Unsure 4

5 SNF PPS Final Rule FY2012 Rates are decreasing by an average f 11.1% Parity r recalibratin adjustment 12.6% decrease Market basket 2.7%, less 1.0% prductivity adjustment = 1.7% net increase Cuts nly apply t therapy categries Nn-therapy rates actually went up slightly by net market basket increase 5

6 Rehab Rates Cmparisn (Urban, nt wage adjusted) Categry FY 2011 Urban rates FY 2012 Urban rates Decrease RUX $ $ (132.34) RUL (126.32) RVX (130.60) RVL (109.68) RHX (128.52) RHL (107.55) RMX (123.06) RML (111.22) RLX (114.75) RUC (75.48) RUB (75.48) RUA (45.52) RVC (72.13) RVB (52.73) RVA (52.76) RHC (70.05) RHB (58.15) RHA (44.74) RMC (67.78) RMB (58.70) RMA (40.83) RLB (74.27) RLA (33.87) 6

7 Clinical Rates Cmparisn (Urban, nt wage adjusted) 7 Categry FY 2011 Urban rates FY 2012 Urban rates Increase ES3 $ $ ES ES HE HE HD HD HC HC HB HB LE LE LD LD LC LC LB LB CE CE CD CD CC CC CB CB CA CA

8 Parity Adjustment Transitin frm RUG III t RUG IV in FY2011 was intended t be budget neutral Payments t prviders fr SNF days Octber 2010 thrugh April 2011 were higher than CMS prjected Payment increases largely attributable t Higher than anticipated therapy utilizatin Increased utilizatin f ultra high & very high rehab RUG categries 8

9 Expected vs. Actual RUG Distributin RUG Categry Grups Rehab + Extensive Services FY2009 actual RUGs III distributin CMS prjected RUGs IV redistributin Actual distributin Octber 2010 t April % 4% 3% Rehab Only 51% 79% 89% Ttal Rehab 90% 83% 92% Ultra High & Very High 62% 37% 73% Clinical 10% 17% 8% 9

10 Parity Adjustment N retrspective recvery f current verpayments Cuts fr FY2012 intended nly t decrease future payments, nt recup FY2011 verpayments BUT Ptential impact n FY2012 rates f ther prvisins in final rule was nt cnsidered 10

11 Objectives Understand impact f PPS changes Understand MDS frm changes Understand new OMRAs Knw changes t grup therapy Understand changes t PPS assessment Learn hw t imprve MDS & claim accuracy thrugh effective strategies 11

12 2012 Final Rule Changes Effective Octber 1, 2011 MDS/PPS assessment schedule New Other Medicare Required Assessment (OMRA) CMS clarificatins Grup therapy 12

13 PPS Assessment Schedule 13

14 New PPS Assessment Schedule Effective Octber 1, 2011 CURRENT SCHEDULE NEW SCHEDULE Assessment Type Cde Applicable Medicare Payment Days Assessment Reference Date Grace Days Assessment Reference Date Grace Days 5 day r Readmissin 01, Days 1-5 Days 6-8 Days 1-5 Days day Days Days Days Days day Days Days Days Days day Days Days Days Days day Days Days Days Days

15 PPS Assessment Schedule Why change???? Avid verlapping & duplicatin f data Example 5-day assessment with ARD n Day 8 f stay & 14-day assessment with ARD n Day 11 have fur verlapping days Mre accurately reflect resident status Example Interview f 14-day assessment will better reflect that persn during payment perid 15

16 Transitin fr Implementatin CMS Plicy Summary: In rder t reduce verlap between assessment lkback perids, Effective fr FY 2012 (beginning Octber 1, 2011), facilities will utilize the revised MDS assessment schedule in Table 10B in the FY 2012 SNF PPS prpsed rule (76 FR 26389), which was finalized in the FY 2012 SNF PPS final rule (76 FR 48517) 16

17 Plling Questin Is yur facility at greater risk fr CMS medical review if grace days are used frequently? Yes N Unsure 17

18 New PPS Assessments 18

19 New PPS Assessments Other Medicare Required Assessments (OMRAs) End f Therapy (EOT) OMRA-clarificatin End f Therapy-Resumptin (EOT-R) OMRA (Nt cnsidered NEW assessment) Change f Therapy (COT) OMRA 19

20 EOT Clarificatin Prviders are required t cmplete an EOT OMRA when resident in Rehab RUG des nt receive therapy services fr 3 cnsecutive days, regardless f reasn fr discntinuatin f therapy. Planned (discharged) Unplanned (refusals, appintments, illness f patient, illness f therapist, hlidays) Setting f ARD fr the EOT is unchanged. Yu still may set yur ARD n Day 1, 2 r 3 after discntinuatin f therapy services Recmmend d nt SUBMIT immediately because 20

21 ARD f EOT (Example) Friday Saturday Sunday Mnday Tuesday Therapy EOT ARD Tx Ends Day 1 Day 2 Day 3 21

22 EOT R (Resumptin) If therapy resumes within 5 days & RUG level stays unchanged frm previus assessment. Facility cmpletes an EOT-R r mdifies EOT t an EOT-R and submits New therapy rder r evaluatin is nt required 22

23 EOT-R OMRA Therapy services resume within five cnsecutive days after last day f therapy Resume at same rehab RUG categry N new therapy evaluatin r SOT OMRA required A0310C = 2 r 3 Cmplete O0450A & O0450B (new) 23

24 EOT-R OMRA Example Therapy ends Day 35 f stay Resumes at same level by Day 39 f stay Resumptin date is reprted n EOT OMRA, if EOT OMRA has nt been submitted If submitted, cmplete mdificatin t EOT OMRA 24

25 Plling Questin Des yur facility submit yur PPS assessments within the same week as cmpletin? Yes N Unsure 25

26 EOT Mdified t EOT-R Patient received therapy Mnday Friday Therapy nt prvided Saturday & Sunday Mnday, patient refused therapy EOT OMRA nw required Tuesday therapy was missed due t appintment Missed therapy did nt result in change in clinical cnditin that wuld make him tlerate less therapy & change his RUG- IV classificatin EOT OMRA cmpleted with ARD f Mnday On Wednesday, EOT is mdified int EOT-R by reprting actual date f resumptin, which was Wednesday 26

27 EOT-R OMRA If therapy des nt resume by 5 th cnsecutive day, SNF may nt cmplete EOT-R OMRA SOT OMRA with new therapy evaluatin can be cmpleted 5-7 days after first day therapy starts (ptinal) 27

28 CMS Transitin Instructins Effective fr all EOT-OMRA assessments with an ARD n r after Octber 1, Effective Octber 1, 2011, facilities will be cnsidered 7-day facilities fr the purpses f setting the ARD fr an EOT OMRA. As Octber 1, 2011 is a Saturday, this day shuld be cunted as a day f missed therapy if a patient des nt receive any therapy services n that day. 28

29 CMS ABN clarificatin Inquiries as t issuing ABN weekly n Friday ABN shuld infrm beneficiary f prviders belief Medicare will n lnger pay fr SNF stay CMS expects unplanned discntinuatin t be rare If unplanned discntinuatin in services ccur repeatedly, prvider shuld evaluate if patient cntinues t meet Medicare cverage criteria 29

30 Plling Questin As prviders, are yu mnitring patients therapy minutes beynd lk-back perid fr assessments? Yes N Unsure 30

31 Change Of Therapy (COT) OMRA Required when Patient in RUG-IV Rehab therapy grup has change in intensity f therapy services (ttal RTM* delivered) n lnger reflect classificatin & payment assigned New type f PPS assessment Uses same item set as EOT OMRA *RTM - Reimbursable therapy minutes 31

32 COT OMRA ARD f COT OMRA set fr Day 7 f COT bservatin perid COT bservatin perid is rlling 7-day windw Beginning day fllwing mst recent PPS assessment (scheduled r unscheduled) r Beginning day therapy resumes when an EOT-R OMRA is cmpleted 32

33 COT OMRA Example ARD f 14-day assessment is Day 14 f stay Day 1 f COT bservatin is Day 15 f stay Facility required t review therapy minutes fr week f Day f stay ARD f COT OMRA wuld be set fr Day 21 f stay, if ttal RTM changed RUG classificatin If n change in RTM n COT OMRA required Next evaluatin f patient s ttal RTM fr purpses f cmpleting COT OMRA, wuld ccur n Day 28 f stay (new COT bservatin perid Day 22-28) 33

34 Therapy Issues Reimbursable Therapy Minutes (RTM) Therapy minutes necessary t reach r t classify patient int certain RUG-IV categries; given allcatin f individual, cncurrent & grup therapy minutes 34

35 Grup Therapy Revised definitin f grup therapy Therapy prvided simultaneusly t 4 patients wh are perfrming similar therapy activities 35

36 Grup Therapy Allcatin f grup therapy Full time spent by therapy with grup therapy wuld be divided by 4 (by the sftware) t give RTM Example Fr 1 hur f grup sessin, 60 minutes wuld be entered n MDS fr each resident in grup. Sftware wuld divide 60 minutes by 4 t get 15 RTMs, which cunt tward RUG-IV Rehab grup 36

37 Grup Therapy Grup therapy dcumentatin will need t be mre specific Type f grup therapy (Plan f Care) Number f participants in grup Number f ttal minutes Mnitr RTMs during ARD windw 37

38 Therapy Issues Therapy student clarificatin Therapy students wrking in an SNF wuld n lnger be required t be in supervising therapist s line f sight 38

39 Strategies fr PPS 2012 Medicare meeting Triple check Scheduling calendar t mnitr pertinent assessment dates 39

40 Medicare Meeting Meet daily Brief update n all Medicare Part A patients Meet weekly Review Medicare Part A & B Review Prgress-rehab & clinical Meet mnthly Triple check 40

41 PPS Assessment Dates Pertinent dates t mnitr Entry Discharge Medicare start & end dates Therapy start & end dates COT 7-day rlling windw Therapy resumptin date 41

42 Managing PPS Assessments Cmmunicatin between Medicare crdinatr & therapy Change in patient cnditin r status Rehab r clinical Refusal f any skilled services Appintments r LOAs Plan f actin fr Hlidays Discharge plans 42

43 Strategies fr Success Evaluate financial impact f rate reductins n yur rganizatin Cuts based n natinal average verpayments 43

44 Plling Questin Have yu estimated the impact f the final rule n yur facility? Yes N Unsure 44

45 Strategies fr Success ADLs Evaluate & mnitr ADL scring RUG categry ADL scre Natinal % Rehab C % Rehab B % Rehab A % Medically Cmplex E % Equivalent t Medically Cmplex D % C fr Rehab Medically Cmplex C % Equivalent t B fr Rehab Medically Cmplex B % Equivalent t Medically Cmplex A % A fr Rehab 45

46 Plling Questin Is training fr ADL capture part f yur staff rientatin prgram? Yes N Unsure 46

47 Strategies fr Success ADLs ADL examples RUG categry ADL scre Urban rate per day Impact RVC $ 479 difference $ 64 per day RVB 6 10 $ 415 $ 1,920 fr 30 days LD $ 397 difference $ 49 per day LC $ 348 $ 1,470 fr 30 days CD $ 320 difference $ 37 per day CC $ 283 $ 1,110 fr 30 days 47

48 Strategies fr Success Depressin Md interview results (clinical RUG categries nly) Natinal averages 13% with depressin 87% withut depressin Examples f scring depressin RUG categry PHQ scre Urban rate per day Impact HE2 10 $ 454 difference $ 77 per day HE1 0 9 $ 377 $ 1,078 fr 14 days LE2 10 $ 413 difference $ 68 per day LE1 0 9 $ 345 $ 952 fr 14 days 48

49 Strategies fr Success Rates FY2012 Categry Rate per day Rank RUC $ RUB RVC RUA HE HD RHC RVB RVA LE HC HB LD HE RHB CE RMC RLB HD LC

50 Strategies fr Success Rates 2012 Categry Rate per day Assume PPD Therapy $1.05 / minute Net Rate per day Rank HE2 $ 454 $ RUC 559 $ (108) RUB 559 (108) HD LE RVC 479 (75) HC HB LD HE RHC 418 (49) CE RUA 467 (108) HD RLB 357 (7) LC CD LE RMC 367 (22) RVB 415 (75)

51 Strategies fr Success Current Care Mdel Current Rates Week 1 Week 2 Week 3 Week 4 Week 5 Ttal Assessment 5 - day 14 - day Dischg Categry RVC RVC RVB RVB Medicaid 28 MC days 7 MD days Rate per day $ $ $ $ $ $ avg Week ttal $ 3,861 $ 3,861 $ 3,275 $ 3,275 $ 1,050 $ 15,322 Therapy min Therapy cst $ 525 $ 525 $ 525 $ 525 ($ 2,100) Reimbursement, net f therapy cst $ 13,222 51

52 Strategies fr Success Current Care Mdel FY2012 Rates Week 1 Week 2 Week 3 Week 4 Week 5 Ttal Assessment 5 - day 14 - day Dischg Categry RVC RVC RVB RVB Medicaid 28 MC days 7 MD days Rate per day $ $ $ $ $ $ avg Week ttal $ 3,356 $ 3,356 $ 2,906 $ 2,906 $ 1,050 $ 13,574 Therapy min Therapy cst $ 525 $ 525 $ 525 $ 525 ($ 2,100) Reimbursement, net f therapy cst $ 11,474 Change frm FY2011 (13.2%) ($ 1,748) 52

53 Strategies fr Success Care Management Mdel FY2012 Rates Week 1 Week 2 Week 3 Week 4 Week 5 Ttal Assessment 5 - day 14 - day COT 30 - day, + COT ARD Day 2 (n SOT) Day 14 (RHC) Day 21 Day 28 Categry HE2 HE2 RUB RVB RVB 35 MC days Rate per day $ $ $ $ $ $ avg Week ttal $ 3,181 $ 3,181 $ 3,912 $ 2,906 $ 2,906 $ 16,086 Therapy min Therapy cst $ 341 $ 756 $ 525 $ 525 ($ 2,147) Reimbursement, net f therapy cst $ 13,939 53

54 Strategies fr Success Re-evaluate yur care mdel 54 Resident s clinical needs as imprtant as therapy needs Mnitr & train ADLs Capture depressin fr clinical RUG categries Understand hierarchy f all RUG rates Cnsider cst f therapy when selecting RUG categry Manage delivery f care frm admit t discharge Wrk as an interdisciplinary team D pre-assessment screening Evaluate all resident s needs Cmpare ALL ptential RUG categries Plan apprpriate care Set ARDs fr mst benefit

55 Strategies fr Success Partner with yur therapy prvider Make sure they are n bard Negtiate adequate payment fr therapy services, even in nn-rehab categries Manage expectatins Staff Physicians Family Re-examine philsphy Influence behavirs 55

56 56 Questins?

57 Upcming Webinar Issues in Unrelated Business Incme fr Health Care Thursday, September 8, 10:00-11:00 a.m. Central time T register r fr mre infrmatin g t 57

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60 Lri Brunhltz Directr Suzy Harvey Supervising Cnsultant