By Janine Savage, RN, RAC-CT, CHC

September 26, 2019, The Centers for Medicare & Medicaid Services (CMS) issued a Final Rule addressing acute care to post-acute care (PAC) discharge planning. There are many complex and detailed requirements and prohibitions in this Final Rule that aim to improve patient engagement and decrease hospital readmissions. It calls out several laws and regulations that have caused compliance concerns about discharge planning for many years, and it is the most comprehensive regulatory rulemaking on this topic to date.

What does the Final Rule Address?  

The Final Rule addresses care transitions, coordination of care, interoperability, and patient choice. It not only allows hospitals to share information about quality related to PAC providers, but it requires them to do so – while prohibiting hospitals from developing “preferred provider” lists.

The rule also addresses interoperability, which has been an increasing focus of CMS. Hospitals must ensure and support patients’ rights to access their medical records in the format requested by the patient, if they are readily producible in that format (including electronic when medical records are maintained electronically).

This rule implements requirements from the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). If a patient is being discharged to a PAC provider, it requires the hospital’s care team to assist patients (or their family or representative) in selecting a PAC provider by sharing key performance data about that provider that is relevant and applicable to the patient’s goals of care and treatment preferences. It specifically refers to the quality measures and resource use measures that are prescribed by the IMPACT Act.

The Discharge Planning Final Rule’s effective date is 11/29/2019. For more information, access the CMS Fact Sheet.

How PointRight Helps

PointRight solutions help hospitals meet the requirements of the Final Rule and achieve a comprehensive and compliant discharge planning process by assisting patients in selecting a PAC provider that best meets their needs and preferences. The features of PointRight solutions go far beyond that of Nursing Home Compare and are specifically designed for this purpose.

PointRight’s ScoreCard supports discharge planning to SNFs by providing patients with a customized list of SNF providers in the geographic area they request, with key performance and quality outcomes data relevant and applicable to their goals of care and treatment preferences.

PointRight’s Home Health ScoreCard supports discharge planning to home health with quality and resource use information about home health agencies that service the patient’s home county. (Contact us to learn more.)

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Author:

Janine Savage, RN, RAC-CT, CHC
Vice President, Product Management, PointRight

Janine is Certified in Healthcare Compliance (CHC) and leverages her knowledge of relevant regulations and expertise in compliance processes to assist organizations in promoting organizational integrity through the operation of effective compliance programs.

By Janine Savage, RN, RAC-CT, CHC

In one of my past roles, I was a Corporate Compliance Officer for a long-term and post-acute care provider. I still maintain my CHC (Certified in Healthcare Compliance) credential through the Healthcare Compliance Board and stay connected to the LTPAC compliance community.  Understandably, there is a lot of discussion about what will happen from a compliance and enforcement standpoint now that the Patient-Driven Payment Model (PDPM) has been implemented. Back in May 2019, I speculated that documentation and accurate coding would be key to PDPM success – and this is still true now that October 1 has come and gone. 

PDPM Guidance from CMS

CMS has been very clear about compliance risk areas for providers under PDPM. In CMS’ provider training, John Kane stated specifically, “Given the more holistic style of care emphasized under PDPM, program integrity and data monitoring efforts will also be more comprehensive and broad. For program integrity, we expect provider risk will be more easily mitigated to the extent that reviews focus on more clearly defined aspects of payment, such as documentation supporting patient diagnoses and assessment coding.”¹

Beware of PDPM ‘Optimizers’

There are some PDPM tools out there that allow you to get the highest payment without any regard to supporting documentation. One example, a diagnosis optimizer, allows you to select any ICD-10 code from a hierarchical list, whether or not that code has been assigned to that particular resident through proper diagnosis coding procedures, which of course would include a comprehensive review of the patient’s medical record documentation. This concerns me (and many other compliance professionals!) because we already know the compliance-related lessons that have been learned from other types of healthcare providers who used similar approaches in the past. From a compliance perspective, you should use only tools that help you get the highest payment that your medical record documentation actually supports.

Rely on Proven MDS Audit Applications

Some LTPAC EHR and billing software vendors are offering MDS audit features and MDS analytics within their applications. From a compliance perspective, you’ll be best-positioned if you use a well-respected and proven third party application that is separate from your EHR to audit your reimbursement-related MDS coding. The proverbial fox guarding the henhouse concept applies here. And beware of anything that’s free – in my experience, you usually do get what you pay for!

By following compliance best practices in your auditing and monitoring activities, in the event of an audit or investigation, you’ll be much better-positioned to keep the PDPM reimbursement dollars that your teams are working very hard to achieve.

Author:

Janine Savage, RN, RAC-CT, CHC
Vice President, Product Management, PointRight

Janine is Certified in Healthcare Compliance (CHC) and leverages her knowledge of relevant regulations and expertise in compliance processes to assist organizations in promoting organizational integrity through the operation of effective compliance programs.

Sources:

¹ CMS Quality Reporting Program Provider Training; “Patient Driven Payment Model: What is Changing (and What is Not)” slide 65; Centers for Medicare & Medicaid Services, May 8, 2019.