Identify the areas of compliance risk to monitor now and going forward.
In the first blog of this series, we shared key data patterns and trends that every SNF provider should be evaluating within their own organizations. Perhaps you were inspired to go back and determine where you stand. If you did, were you surprised? Or perhaps the better question is – do you have access to this level of data to know your data patterns?
Let’s take a closer look at why it is critical that you know your data and can defend it should the need arise.
Compliance programs are a foundational part of monitoring in today’s market. A compliance program demonstrates your commitment to honest and responsible business conduct and is intended to allow you the ability to recognize potential issues and correct them quickly. It’s also a requirement under Section 6102 of the Affordable Care Act (ACA). This nursing facility mandate aims to ensure an effective compliance and ethics program that is living and breathing in the organization and not just paper compliance.
How Does PDPM Impact Compliance Programs?
Most of us understand what a compliance program looked like under the RUGs system, but how does PDPM change the program? This quote from the 2019 Provider QRP Training: “Patient Driven Payment Model: What is Changing and What is Not”, CMS clearly lays out their intentions for ensuring program integrity and data monitoring. I’m not sure how much clearer they could get.
The most important sentence above is “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.”
Documentation supporting patient diagnoses and assessment coding. Not a new concept, but CMS is being very transparent here and showing us specifically what we need to be successful with PDPM. These “defined aspects of payment” such as the comorbidities, and the nursing and speech component related factors are exactly what providers should be focusing on. Any element that increases the per diem payment and could potentially be manipulated for higher payment should be monitored closely. Interdisciplinary team members who are coding the MDS and documenting may be too close to the problem and may not readily see missing or conflicting information. Perhaps a cross team review process is a more effective approach to make sure the important aspects of supportive documentation are present and consistent.
In a recent webinar, “PDPM: Looking Back & Planning Ahead,” we asked the audience of over 200 providers whether they had added monitoring of the PDPM rate drivers to their compliance plan. Slightly over half of attendees have recognized the need to be vigilant with these drivers, while the remainder either didn’t know or have not made any plans to add them. This is a crucial step for overall compliance and risk mitigation. Now it’s your turn.
Have you adjusted your compliance plan to include the PDPM rate drivers?
It’s not too late if you haven’t. Many providers and CMS themselves have been a little occupied with a public health emergency, but it’s only a matter of time before CMS resumes their data analysis and audits. Now is the time to sit down with your leadership team and determine what you will monitor and how. Perhaps it’s time for your annual review. Federal regulations (FTag 895 in the State Operations Manual) require “the operating organization for each facility must review its compliance and ethics program annually and revise its program as needed to reflect changes in all applicable laws or regulations and within the operating organization and its facilities to improve its performance in deterring, reducing, and detecting violations under the Act and in promoting quality of care.”
Adjustments to your compliance plans should also include the newly emerging areas of risk with COVID-19 and the use of Extensive Services for isolation.
Are Your QMs Telling a Story that Increases Your Risk?
One pre-COVID story that’s possible for this QM is that with the transition to PDPM, they changed their therapy delivery to using more group/concurrent therapy and reduced the time spent with residents and within 2 months, their measure dropped dramatically. That might not be what happened, but again the data can tell different stories to those looking in from the outside and this is where your proactive responses are critical.
Study the trend, document your findings and develop your plan of action to address it.
Watching your trends closely is very important right now – we’re in a strange time. Changes in your outcomes can happen very insidiously – even when you’re below the national average, you still should consider this a potential problem and investigate this negative trend. The graph at left is a great illustration of slow, but steady increase in rehospitalizations.
Addressing Compliance Risk: Where do you go from here?
In the third and final part of this series, we will provide simple, yet crucial strategies to ensure you know your data, can defend your data, and position yourself for PDPM success. Stay tuned!
Check out Part 1 of this PDPM: Looking Back & Planning Ahead series, Key Insights in SNF Data from the Transition to PDPM.