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We’re now well past the one-year mark of the shift from RUGs to the patient driven payment model (PDPM), which means it’s probably time for an annual checkup. And if you’ve already been researching ways to fine-tune your efficiencies and maximize your results, you’ve probably come across terms like MDS scrubbers and data audits.

Effectively utilizing one of these tools can be a game-changer when it comes to improving data accuracy, ensuring compliance, and achieving the reimbursement for the care you provide.

What is an MDS Scrubber and is it Important?

MDS Coordinator Checking DiagnosesThe minimum data set (MDS) assessment is the standardized and federally mandated clinical assessment of patients in your facilities that serves as the basis for the assessment and care planning process. For many patients, it also determines how much you’ll be reimbursed for their care.

As your MDS Coordinator and interdisciplinary team complete the MDS, it’s critical that the data coded on the assessment is complete and accurate. Identifying errors, catching missed conditions, and correcting inconsistencies in real-time can make a significant difference in reimbursement rates. And an accurate assessment is crucial for a comprehensive and individualized patient care plan.

An MDS scrubber can help, checking each of your MDS assessments prior to submission to the Centers for Medicare and Medicaid Services (CMS). Many scrubbers use the CMS validation edits to ensure data on the MDS is in the proper format, all required fields have been completed, any “skip patterns” of MDS items are correct, and date items make logical sense.  

Taking MDS Scrubbing to the Next Level

MDS scrubbing is a great place to start. However, for those SNFs looking to truly change the game, Data Integrity Audit (DIA) is a much stronger approach. Not only does DIA check for the basics like a scrubber does, it provides feedback on MDS coding from clinical, regulatory, financial, and risk management perspectives.

MDS coding errors and coding inconsistencies are identified, along with alerts to quality measure and reimbursement issues that need to be reviewed before submitting the assessment to CMS. By using a much more comprehensive and analytics-driven approach, you’re setting your team up for success.

Some of the benefits of DIA include:
  • More accurate reimbursement
  • Improved quality measures
  • More individualized care planning
  • MDS coding support for your team members
  • Compliance check by a third party outside your EHR software

Additionally, DIA provides guidance and recommended actions to address identified issues. It helps to build a practical learning and feedback loop to drive continuous improvement for your team. Identifying issues is step one; knowing how to correct them is where you find the greatest benefits.

Claims-based versus MDS-based Insights:
The Differences Are Profound

Senior Healthcare Specialist Jennifer Gross explores the source of MDS and claims data while explaining the advantages of leveraging insights from both.

Get Your Guide

Is the more in-depth audit worth it? Check the numbers.

Here are some highlights from the facilities using the DIA solution offered by PointRight, a Net Health data analytics company:

  • Average Medicare Part A per diem rate increase of $4.16 per day (an additional of at least $50,000 per year for a typical facility)
  • 12% fewer total health inspection deficiencies
  • 6% reduction in total health inspection deficiencies on the first survey after implementation
  • Users who stopped using the solution saw an average of a 3% increase in the total number of deficiencies and a 25% increase in immediate jeopardy deficiencies on their first inspection afterwards

*All statistics are on average

The numbers are clear that implementing a DIA can bring marked and measurable results—and fast. It fits easily and seamlessly into your team’s existing MDS workflow and provides them with the decision support they need to give your facility a clear advantage with PDPM reimbursement and quality outcomes.

If you’re interested in seeing what PointRight’s Data Integrity Audit can do for your operations, reach out today for a demo.

Filed Under: Blog

Do Intentional and Unintentional Increases in Patient Acuity Present a Problem for SNFs in 2021?

One of the best ways to educate ourselves and prepare to plan for success is by studying the data we have available to look for trends and opportunities to grow and preempt potential pitfalls. For those of us in the SNF industry, a 2020 trend that stands out as a prime candidate for analysis is the rise in overall patient acuity.

While much of the data on rising patient acuity makes sense as an expected byproduct of the COVID-19 pandemic, there is more we should look at to ensure we’re prepared for some potential hurdles this trend may bring (or may already be bringing) in 2021.   

Let’s Start with the Numbers

Woman viewing charts on laptopPointRight, a Net Health data analytics company serving the skilled nursing industry, recently analyzed the changes in rate driver percentages year-over-year within its SNF customer base from FYQ4 2019 (pre-PDPM and pre-pandemic) to FYQ4 2020 (post-PDPM and post-pandemic).1

Here were the results:

  • Extensive services (which includes isolation, trachs, and vents) increased nearly 5x – (2.2% to 10.2%)
  • Depression increased over 2x – (4.9% to 11.3%)
  • Cognitive Impairment increased 4x – (13.0% to 52.2%)
  • Restorative Nursing increased almost 2x – (1.6% to 2.6%)
  • Swallowing Disorders increased almost 4x – (4.7% to 17.4%)

Not only does this confirm the rise in patient acuity, but it shows just how dramatic it really was. The cause of these rises is surely a mix between the effects of COVID-19, as well as some SNFs pivoting their resources and capabilities to alter their patient mix to capitalize on higher reimbursements from more medically complex patients.

The Challenges We May Face

Now that we understand the rise in patient acuity and have a good grasp on why it’s happening, we can start looking at the potential challenges we may already be facing or will soon face in 2021.

Logistical and Staffing Considerations

More medically complex patients drive a higher reimbursement because they require higher levels of care. This means that we need to be prepared to better allocate our resources, schedule the necessary training for our staff, and address any staffing concerns to handle the higher level of care. Throw in the fact that we may find ourselves unexpectedly short-staffed at times due to COVID-19 quarantines, and the need to be prepared grows.

Compliance Concerns

While the Centers for Medicare and Medicaid Services (CMS) have been busy with COVID-19, it’s an organization that’s never too preoccupied to address compliance concerns. While many of the increases in patient acuity logically make sense, it’s hard to ignore that some of the jumps are pretty sizeable.

Increased Needs for Documentation

Here’s the good news. As has always been the case for SNFs, if you have the documentation to back up your care, you have nothing to fret about. And while we already all strive to have the most complete documentation on our patients, that all gets infinitely more important when we see rises in patient acuity and potential indicators that CMS and providers might be preparing to ask questions.

Download eBook on SNF Challenges
SNFs , how can you weather the storm while finding unique ways to grow? If you’re interested in learning more about how you can set your SNF team up for success facing these challenges, take a minute and check out our free e-book—4 Biggest Challenges Facing SNFs in 2021.
Download eBook

The Solution: Data-Driven Decision Making

A lot of this can feel overwhelming. We’re in uncharted territory, there’s a lot on the line, and all we just want to offer the highest level of care for our patients, keep our staff taken care of, and keep our businesses moving forward.

Thankfully, we don’t have to go it alone. One of the most powerful tools we have at our disposal that’s devoid of being impacted by the noise is data. And for the SNF concerns we’ve outlined, it’s the perfect remedy.

If you’d like to take the next steps to begin reacting to rising patient acuity, we have some additional resources. First, we’d encourage you to check out our free e-book titled 4 Biggest Challenges Facing SNFs in 2021 that digs deeper into this topic.

Second, we’d encourage you to see how PointRight may be able to help you better capture the data you have available and turn it into easy-to-read information for more effective data-driven decisions. 

  1. PointRight, “PDPM Year 1 – Dive into Your Rate Driver Data”, Maria Arellano, MS, RN, RAC-CT.

Filed Under: Blog

Ask any middle school student in a science class how many variables you should change when testing something new and you’ll get a resounding chorus of the right answer—one. In 2020, SNFs and the Centers for Medicare and Medicaid Services (CMS) were collectively excited to follow this guidance with the transition to the Patient Driven Payment Model (PDPM).

MDS Coordinator Checking DiagnosesHowever, COVID-19 and the ensuing public health emergency (PHE) had a different plan. And as a result, it’s been a challenge for all of us within the industry to know how to interpret the early PDPM data, where to attribute causation, and, most importantly, how to react.

The truth is, though, rarely does the real world allow for testing in a vacuum to generate perfect data. Therefore, it’s still important we do our best to pull meaningful trends to drive our plans forward into 2021.

Early Assessments of PDPM Rate-Driver Data Show Trends

Recently, PointRight, a Net Health company, conducted and published a data analysis of its userbase looking at the year-over-year changes in rate-driver percentages from FYQ4-2019 (Pre-PDPM) and FYQ4-2020 (Post-PDPM).1

The bottom line up front is sizeable increases in several rate-driver categories:

  • Extensive services (which includes isolation, trachs, and vents) increased nearly 5x – (2.2% to 10.2%)
  • Depression increased over 2x – (4.9% to 11.3%)
  • Cognitive Impairment increased 4x – (13.0% to 52.2%)
  • Restorative Nursing increased almost 2x – (1.6% to 2.6%)
  • Swallowing Disorders increased almost 4x – (4.7% to 17.4%)
Download PDPM Rate Driver Data eBook

Free e-book Assessment of PDPM Rate-Driver Data Shows How SNFs Performed in 2020 showcases the data, conducts analysis to draw meaningful trends, and provides strategies on how best to react.

Download eBook

Could This Be Problematic?

On the surface, this probably looks great to a lot of providers. As PDPM reimbursement is based on the medical complexity of patients, this could mean a boost to the balance sheet. For example, CareTrust REIT saw its skilled-mixed occupancy increase by 270 basis points from Q3 to Q4 of 2020.2 Even in the face of the company’s SNF occupancy dropping by 154 basis points during that same time period, the company still saw a fourth-quarter net income increase to $21.1 million, up from $20.6 million year-over-year.

post acute performanceBefore SNFs in similar situations begin celebrating, though, there are questions we need to be asking about these trends.

  • Should we be concerned that CMS and providers will scrutinize the dramatic increases in patient acuity?
  • If (and possibly more correctly—when) will we see adjustments to PDPM payments as a result?
  • How many of these financial wins can be attributed to the shorter-term effects of the PHE?
  • Will SNFs see the same positive results under PDPM if and when patient acuity returns to pre-pandemic levels?

Two Steps To Consider Taking Today

If you’re looking for a path forward in response to these concerns, there are two things that can help.

First, we’d encourage you and your team to dig deeper into PointRight’s rate-driver data study to better understand the industry as a whole and begin benchmarking where your operation sits in relation.

Second, begin looking at what systems you have in place to track similar data and how you’re documenting your care. A rise in patient acuity and reimbursement isn’t automatically a red flag, as long as you’re aware of the trends and you’re able to back those trends up with the right documentation.

  1. PointRight, “PDPM Year 1 – Dive into Your Rate Driver Data”, Maria Arellano, MS, RN, RAC-CT.
  2. PDPM revenue, caring for COVID patients ‘significantly offsetting’ CareTrust’s decline in occupancy, Danielle Brown, February 12, 2021. 

Filed Under: Blog

Though I live in Massachusetts today, my childhood and early college years were spent in Maryland. It has a special place in my heart and many of my family still live there. The other reason Maryland is special to me is we collaborate with a great group of health systems and providers there who have made post-acute care partnerships a cornerstone of their strategic plans. Quarterly these health system leaders as well as other key stakeholders meet for a shared learning experience to improve care coordination, tackle emerging population health initiatives, and overcome barriers. They share best practices to enhance the partnerships with their SNF and Home Health providers as they all work collaboratively with a common goal on quality improvement.

We call ourselves the Maryland Post-Acute Care Collaborative (#MDPACCollab).  There are approximately 30 hospitals representing  five health systems.

Earlier this year, I had the pleasure of chatting with two collaborative members:

  • Cindy Kelleher, President & CEO, University of Maryland Medical System (UMMS) Rehabilitation & Orthopaedic Institute
  • Joe DeMattos, CEO, Health Facilities Association of Maryland (HFAM)

I wanted to find out what systems or relationships they had in place when COVID-19 hit that they felt enabled them to meet the challenge more readily.

Executive Chat with UMMS, HFAM and PointRight

Power of Post-Acute Partnerships in the Midst of a Pandemic

 

Timestamps

3:12 – Sharon (PointRight): How did you know who to call in your skilled nursing partners when COVID-19 emerged?

Cindy (UMMS): We had already been working on our post-acute care collaborative so we’d been in touch with some of our skilled nursing facilities. So we definitely knew our skilled nursing partners and we just started to call them with the support of Joe.  We started to talk to them about what did they need, what did they see coming and mutually, how can we help you and what do you need from us? 

4:55 – Sharon (PointRight): What happened when you got Cindy’s call?

Joe (HFAM): I was positively overwhelmed and knew that I had a safety net early in the process and that was incredibly important as we started fighting this pandemic together. One of the things that I want to say is that early on, it was because of Cindy’s work with the post-acute partners directly involved with UMMS that we even had any sense of integrated public reporting around COVID today.

8:25 – Sharon (PointRight): What were you tackling on your daily calls with Joe?

Cindy (UMMS):  We developed a very trusting relationship, so Joe and I, and the Maryland Hospital Association, our thinking evolved very quickly, which was critical. I think that’s what made us successful, having that trust, having Joe’s connections through HFAM, having my connections through the hospital, getting consensus quickly. There was an incredible level of trust built, and then trying to gather all that data and see where this is going. 

12:05 – Sharon (PointRight): What were some of the learnings from visiting SNFs? 

Cindy (UMMS): It was important to support them and speak out at a time when there was a lot of negativity around what they were doing, and I think that we really need to educate a lot of people that it had nothing to do with bad this or bad that, it had a lot to do with the level of COVID in the community.

18:20 – Sharon (PointRight): What do  you see as points of collaboration and needs in future?

Cindy (UMMS): This became a very expensive process for all of us. If you start to add up what skilled nursing homes and even hospitals had to do around paying for the testing, paying for the PPE, paying for staffing, and you look at their cost structure, I’m still concerned as to how skilled nursing can provide a very sick population with all these things. And I think it’s shown us in general some of the weaknesses. We survived this because we had partnerships and relationships and people were willing to get on board.

19:45 – Joe (HFAM): I think the tracking mechanisms, the ED transfer form, the mining data for knowledge – all of that will serve us well. The dialogs we had related to surge management, we had critical conversations behind the scenes on that, that will serve us well in the future. Also our partnerships with the Maryland Hospital Association, and also specifically Cindy and I and our partnerships with county health offices and state epidemiology branches, our work on that front will serve us well. 

strategic framework for post-acute analytics
Post-Acute Analytics: A Strategic Framework for Hospitals & ACOs

Free guide explores the pros and cons of different post-acute data source while also presenting a three phase approach to network management excellence.

Get Your Guide

Filed Under: Blog

A year ago we thought PDPM would be the biggest challenge of 2020. But COVID is not a compliance smokescreen and the devil is in the details and the details are in the rate driver data.

As you reflect on 2020 and plan for 2021, the analysis of your Patient-Driven Payment Model (PDPM) data must remain a high priority. Despite the unique challenges 2020 provided, the expectations of high quality care and compliance remain. So, while we can evaluate the data in the context of COVID and rationalize concerning trends, the reality is that CMS is still watching skilled nursing facility (SNF) provider behavior. 

Compliance amidst COVID Chaos

Yes, CMS has been busy with COVID, too, but not so busy that they will not investigate potential compliance issues. The PDPM rate driver data for the final quarter of FY 2020 did not change dramatically from the trends we discussed in earlier blogs, but it is certainly worthy of a revisit so we can start the conversation about what these trends may mean.  

Have the rate driver percentages stabilized, or will they decrease once we are past the COVID crisis?

What was COVID-19’s impact on PDPM?

Here’s what a few PointRight clients have shared about positive and negative impact:

  • Higher nursing case mix groups due to increase in need for isolation, vents, and trach care
  • Higher Non-Therapy Ancillaries (NTAs) due to increase in comorbidities common in patients with COVID
  • Opportunity to develop COVID dedicated units to maintain census and develop positive relationships with referral partners
  • CMS’ COVID Waivers provided opportunity to deliver skilled care and services “in facility” which typically garner higher reimbursement
  • Multiple missed opportunities to capture accurate coding due to pulling MDS Coordinators to cover staffing challenges
  • Challenges completing resident interviews due to isolation and quarantine leading to coding inaccuracies
  • Physical plant challenges providing isolation that complies with RAI Manual definition
Don’t forget the CMS language in the 2019 SNF PPS Final Rule…
 “…with regard to the potential impact of PDPM on patient care, specifically the possibility that some providers may stint on care or provide fewer services to patients, we plan to monitor closely service utilization, payment, and quality trends which may change as a result of implementing PDPM. If changes in practice and/or coding patterns arise, then we may take further action, which may include administrative action against providers as appropriate and/or proposing changes in policy (for example, system recalibration, rebasing case-mix weights, case mix creep adjustment) to address any concerns. We will also continue to work with the HHS Office of Inspector General, should any specific provider behavior be identified which may justify a referral for additional action.” [ Source: CMS.gov ] SNF Data Impacted by COVID
[ Get your PDPM Self-Assessment Guide ]

PDPM Rate Drivers – What do they reveal?

Let’s break down the rate drivers to expose the potential audit vulnerabilities.

Extensive Services

PDPM Rate Driver Table - Extensive Services

I do not think anyone is surprised that there is an increase in coding of this nursing case mix group (CMG) because this is where isolation, trachs, and vents are captured. The jump in ES in FYQ3 aligns perfectly with COVID, but do not be too complacent here. CMS may see this as a potential area of fraud and dig deeper to make sure the definition of isolation in the RAI manual was followed. This case mix group (CMG) could likely remain high through early to mid 2021 depending upon the status of the pandemic.

Depression/Cognitive Impairment

Depression and Cognitive Impairment PDPM Drivers

A huge red flag for all providers should be the more than doubling of MDSs coded with depression and more than tripling of cognitive impairment in FYQ1. It is highly unlikely that the entire nation had a dramatic increase in residents with these conditions suddenly being admitted to their facilities. Now that depression and cognitive impairment drive the rate, there is certainly an incentive to capture them. But if your documentation supports your coding, don’t fret. We all know that if we provide additional training and focus on an area, we typically will see improvement in assessment. But you may want to consider documenting all your unusual trends and subsequent investigation in the QAPI committee minutes and confirm that this is truly the case. Consider any changes you made to the interview process or interviewer as well.

Restorative Nursing

Restorative Nursing PDPM Rate DriverThis PDPM rate driver saw a much slower increase but still nearly doubled from pre-PDPM to FYQ3. However, capturing restorative minutes on a PPS assessment is much harder now if Assessment Reference Dates (ARDs) are set early in the stay because it requires 15 minutes per day for at least 6 of the last 7 days. Earlier ARDs could be a logical explanation, but don’t assume. Test your theory especially if your quality measures may indicate declines in Activities of Daily Living (ADL) function.

Swallowing Disorders/Mechanically Altered Diet

Swallowing Disorder PDPM Payment DriverThe coding of swallowing disorders calculating close to 4x’s the pre-PDPM rate is yet another example of a concerning trend that will likely grab CMS attention. It makes sense that if the swallowing disorders increase, the mechanically altered diets might increase as well. However, not every resident with a swallowing disorder needs a mechanically altered diet, but most residents who are on a mechanically altered diet would have some condition to warrant it such as a recent oral surgery, poor dentition or extreme weakness making chewing difficult. The reason for the altered diet should be clearly documented and re-evaluated for continued need.

Non-Therapy Ancillaries (NTA)

Variability in resident acuity is normal so fluctuations in the distribution of assessments across the 6 NTA case mix groups is expected. Nationally, PointRight customers saw approximately 53% of their assessments land in the lowest two groups. How will CMS perceive high percentages of assessments in the higher CMI groups? We do not have any pre-PDPM comparison since NTAs were not in play prior to October 2019, but it certainly could be a high priority area for auditors. NTAs are a significant multiplier in the per diem calculations so it stands to reason that providing evidence that these comorbidities exist, or services/treatments were provided, will be a crucial step to avoid audit nightmares.

Use of CMS’ COVID related Waivers

The CMS waivers implemented for the public health emergency were a positive approach to helping keep less critical patients out of the heavily burdened hospitals and allowed SNF’s to implement and get reimbursed for the higher level of skilled care provided. However, these waivers will certainly come with retrospective scrutiny.

  • Can you defend the need for skilled care for these residents?
  • Does your documentation show evidence that the extension or early restart of the benefit period has a direct connection to COVID?
  • And do not forget the basics. Do you have all your required Medicare forms completed?

Reviewing your trends in PDPM data is an ongoing process. Your data story can change gradually over time or abruptly with turnover in key positions. How will you monitor to ensure you are telling the real story?

More PDPM blogs:
  • Key Insights in SNF Data from the Transition to PDPM
  • Compliance & Risk & PDPM – Oh My!
  • Strategies for Combating Unfavorable PDPM Trends

PDPM Self-Assessment Guide

Follow the PointRight arrows through this three part assessment and see how your PDPM performance compares to national averages.

PDPM Self-Assessment Guide

Download Guide

Filed Under: Blog

You get what you pay for. For years, CMS paid for volume and that’s exactly what they got- lots of rehab, lots of tests, lots of specialists; lots of volume. But despite paying a lot for healthcare, our national outcomes remained mixed when compared to other similar countries, particularly in the areas of life expectancy, infant mortality, unmanaged diabetes and asthma.

post acute performance

No wonder CMS is focused on value-based payments. The concept is simple – value-based payment leads to value-based care. Why do providers need to care? What CMS does as a pilot many times finds its way into legislation that becomes our reality.

The SNF value-based program that was legislated in 2014 with the Protecting Access to Medicare Act (PAMA) came after CMS saw success with the Hospital Readmission Reduction Program (HRRP). Not only is CMS continuing to focus on outcomes driving payment, they are encouraging states to do the same when allocating Medicaid dollars.

Key Elements of Value-Based Programs

Key elements of a value-based program were outlined in a recent CMS memo sent to State Medicaid Directors:

  • Level and scope of financial risk – Basically, this area addresses what providers are accountable for- all care or a carved-out portion? How much risk will providers assume?
  • Benchmarking – How will the outcomes be measured?
  • Payment operations – How will operators be assigned responsibility for which residents?

State Value-Based Programs

PointRight provides expertise on benchmarks and data aggregation to states so they can develop programs that rely on MDS data to measure outcomes. Working with state agencies and payors, PointRight was able to help create a collaboration that addressed the unique needs of the populations served by the state. [ Check out PointRight’s VBP work with New Mexico ]

With the collection of data from the new federal Patient-Driven Payment Model in about 31 or so states, keep your ears to the ground to listen for potential legislative changes and consider reaching out in advance to participate in pilot programs to get insights on what is happening in your state. Build a great Quality Assurance Process Improvement (QAPI) team that can handle any new initiatives that might develop.

To learn more about Value-Based Programs, check out our recent webinar recording below on the ABCs of VBP. 

More VBP Resources
  • CMS SNF VBP Program Overview
  • CMS State Medicaid Memo 
Claims vs MDS-based insights

Understand your data sources!
Download your guide to understanding claims versus MDS-based insights. 

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Filed Under: Blog

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