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Patient-Driven Payment Model management with new Medicare cuts

This October marks three years since the Patient-Driven Payment Model (PDPM) was first implemented, and some nursing homes are still struggling to adjust.

While a global pandemic and an unprecedented staff shortage are partly to blame for the problems in PDPM-related processes, so is the widespread use of staffing agencies. And now, with a possible $320 million Medicare cut proposed for 2023, specialty nursing facilities are under intense pressure to capture PDPM reimbursement in the most efficient, appropriate, and complete way.

This is according to Lorie Morris, Vice President of Evaluation Coordination at Prestige Healthcare, and Georgie Faulk-Sherwood, Vice President of Clinical Reimbursement at Focused Post Acute Care Partners, who believe that one way for the industry to make better use of reimbursement is by limiting staffing. the agency. use.

“Agency [staff] it doesn’t always give us the information we need to care for a patient, “Faulk said during a recent Skilled Nursing News executive clinical conference in Chicago.

She and Morris talked about how SNFs can better capture PDPM reimbursement with the proposed Medicare cuts on the horizon.

But they also see reasons for optimism. Regardless of when the Medicare cut will be implemented, both Faulk and Morris believe too many facilities are leaving money on the table.

“When I look at the PDPM cuts, I’m probably not thinking as negatively as some people because I know we’re not maximizing right now, we’re missing out on a few things,” Morris explained. “We have to be very good at maximizing [PDPM]. ”


Expectations for PDPM pay cut

Because PDPM is designed to be budget-neutral, the system cannot be more expensive for Medicare and Medicaid Service Centers (CMS) than the Resource Utilization Group (RUG) system. However, it was determined that the model increased payments to nursing homes by 5% in fiscal year 2020.

Although an adjustment to the new Medicare reimbursement system was delayed last year due to Covid-19, giving the SNF a bit of a breather, it turned out to be a slight suspense, as Medicare cuts they return to the table with many SNF experts waiting for them to stay. in its place this time.

Morris, for example, does not believe that the proposed 4.6% cut will change again, although he believes the cuts could be eased at some point along the line.

“I think they end up doing it, but I think we’ll find a way to avoid it,” he explained during the conference.

Faulk agreed that the mandate would be closer, but like others in the industry, he hoped the pay cut would last for several years. The cut will affect how communities can take care of their residents and how staff do it, he added.

“It’s very important that at least if they make that cut, at least they don’t do it all at once, but at least it spreads out a little bit,” Faulk said.

Agency staff impaired MDS coordination

Healthcare agencies have been increasingly criticized for the fees they have charged during the pandemic, with allegations of price increases made across the country. What has most frustrated Morris and Faulk is their compliance, or lack thereof, with the Minimum Data Set (MDS) documentation.

Both proposed limiting the use of agency staff as a way to prepare facilities for the proposed pay cut and improve MDS coordination, although this has been shown to be more easy to say to do for many operators.

For example, Omega Healthcare Investors (NYSE: OHI), one of the largest SNF owners in the United States, reported last week that nursing and agency expenses were more than six times higher in the fourth quarter of 2021 in compared to 2019 for its main portfolio. .

“When you have an agency in your building, they don’t know your residents and it hurts a lot when it comes to documentation,” Faulk explained. “We cannot send an MDS without documentation to support this PDPM diagnosis.”

MDS reports are not only vital to ensure that facilities receive a proper reimbursement for the treatment they provide, but that proper care is being given to patients. If MDS assessments are not completed, there may be regulatory concerns as the RAI (Resident Assessment Instrument) process, which includes the development of MDS-based care plans, is disrupted.

Faulk said the PDPM model is “nursing-driven” and that all the information and diagnoses that nursing facilities are waiting to process a claim or MDS can often be missing when there are agency staff. .

Focused Post Acute Care Partners has had to take “strategic steps” with staffing agencies to avoid such problems, such as not allowing certain temporary workers to enter their buildings due to documentation compliance issues.

Morris uses other nurses to back up her MDS documentation process to make sure it is done correctly.

“When it comes to documentation, I would look at what you ask of your staff,” he said. “Try to find a way to make it easier and look at what’s not critical.”

In fact, the two nursing home leaders recommended making sure there were checks and balances when it comes to MDS coordination.

Focused Post Acute Care Partners uses MDS regional coordinators who review each MDS claim and clinical documentation.

Improve PDPM training for frontline staff

Margins remain tight for SNFs: Long-term care settings in Minnesota saw “abysmal” financial performance in March with an average operating margin of -8.7%, a survey of 156 care centers and 179 long-term assisted living settings. Imperative care revealed.

Given these financial tensions, training in relation to the PDPM process is more important than ever. This training can be essential to ensure that an installation avoids coding errors and missed payments.

“Sometimes it’s just a number or a letter [that leads to a misdiagnosis with PDPM]said Faulk.

According to Morris, Prestige Healthcare essentially returned to its PDPM training throughout the pandemic. Prestige’s particular model focuses on patients with greater acuity, which lends itself to higher pay categories, he explained.

“We went to the staff, not just to train them, but to spend individual time with them and asked them to participate in training from the building,” he said. “I think that helped a lot with the turnover because they were very committed and didn’t leave.”

Focused Post Acute Care Partners has also been looking to “perfect” their education by doing so in smaller groups, and is seeing a surge in staffing and its use of agency reduction.

“We’ve actually renewed much of our education and training when it comes to PDPM because we need this front-line staff documentation,” Faulk said.

Maximize reimbursement through technology

Faulk believes investing in technology is “the way forward” to improve payback processes given the current shortage of staff the industry is seeing.

While the healthcare industry added about 34,300 jobs in April, only 900 of those jobs were in the skilled nursing sector. These figures come after the long-term care industry lost 2,500 jobs in March, further deepening a labor crisis at a level not seen since 2007.

According to Faulk, using technology to streamline documentation and workflows to improve compliance can also help retain staff.

Both Prestige Healthcare and Focused Post Acute Care Partners have also tried to push their medical professionals to become “more electronic” as a way to improve their reimbursement reports.

“Technology has been our friend,” Faulk said. “Especially when you don’t have the consistency of the template.”

Focused Post Acute Care Partners uses a variety of reimbursement software. The company has incorporated technology that can examine a claim after it has been filed and, if something is lost, the software corrects it.

Artificial intelligence systems can also be used not only to correct documentation, but also to identify the person who made the initial graph or the documentation that does not reflect what is really going on with that resident.

“We’ve done surveys with our staff on how much technology we use as an organization, and I would say it’s 80/20,” Faulk said. “There are 20% who say it’s too much and think it takes longer to log in to that particular software and look at this information instead of looking at the chart itself and doing it that way. But 80% like the fact that some reports are already automated. “

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