Skilled nursing facilities (SNF) began operating under the Patient-Driven Payment Model (PDPM) on October 1, 2019. Many current SNF employees have only been exposed to the Resource Utilization Group (RUG) model that was retired on September 30, 2019. The RUG model included therapy groups that ultimately trumped almost anything clinical being treated in the SNF. This may have resulted in minimum data set (MDS) assessments under the RUG model that didn’t include all diagnosis, condition and treatment information simply because it didn’t affect reimbursement.

The MDS assessment was originally created to assist SNFs with developing a comprehensive care plan for residents admitted to a SNF. In the 1990s, the MDS also became a payment tool under the RUG payment model. Consistent focus under the RUG model was on accuracy of therapy days and minutes captured on each MDS assessment. The number of days and minutes of physical and occupational therapy and speech-language pathology (SLP) services was ultimately the deciding factor regarding RUG and daily payment amount.

Important information for Skilled Nursing Facility Admissions, Billers and Finance Departments! New Medicare Part A and Part B Deductibles and Premiums have been released for the 2021 calendar year. Effective January 1, 2021; the following rates will apply:

PDPM Isolation, Quarantine, Skilling, COVID-19, and ICD-10
Top 6 Things to Know

HHI is receiving ongoing inquiries on the MDS Coding qualifiers for Isolation and Quarantine. Although it may seem simple, there is a difference between Isolation and Quarantine.

• Isolation is for patients with symptoms and or positive tests.

• Quarantine is for patients exposed but exhibits no symptoms.

According to the CDC, isolation is for people who are ill, while quarantine applies to people who have been in the presence of a disease but have not necessarily become sick themselves. Per the CDC,

It starts at the front door.

Smart choices upon admission will yield the best results. A strong admissions department will weigh various factors upon admitting a resident, working with the clinical team to select a strong primary diagnosis. This requires a comprehensive review of documentation and transfer paperwork provided upon arrival. By recognizing revenue triggers and selecting the best PDPM category composition; projected reimbursement is established at the highest appropriate level.

Confusion, new directives every hour, residents desperate for help, family, and hope. Your clinical awareness is sharp, on high alert, mindful of any shift in condition. Your all-consuming focus is the health of the patients in your care.

In March 2020, this was the scene in the Long-Term Care landscape. In the blink of an eye, staff intent on treating patients during the pandemic lost the time once dedicated to PDPM initiatives. Fast forward to October 2020, Long-Term Care heroes have helped define “essential”. Our SNF saviors have come out the other side, with techniques and processes to endure the COVID-19 pandemic; and ready to set their sights on the PDPM game once again.

Have you ever felt like your life was an eternal boxing match? Every day you wake up, put your gloves on, and head out just to fight another day. I have felt this feeling many times throughout my life, but nothing has compared to this year of uncertainty and change. As I sit at my desk writing this article, the date is October 1st. Exactly one year ago today the company put on its' boxing gloves and went out to face PDPM. Our company spent over a year planning and preparing for that day and just as we were getting our arms around this new payment system, in came Round 2, COVID-19.

We barely had time to sit in our corner and catch our breath before putting the gloves on to go fight again. With this opponent, we did not have much time for preparation. There was a lot of trial and error and learn as you go. All of our teams bravely stepped up to this new opponent, and I was personally able to see the unwavering commitment from all of you. Six months into this pandemic, we are starting to see the light at the end of the tunnel. But just as we have had a moment to sit in our corner and catch our breath, here comes Round 3!

Illinois is the latest battleground state where Stotler Hayes Group (SHG) has brought the fight for post-Medicaid eligibility income deductions for recipients of long-term care Medicaid benefits. In an ideal world, residents would have all of their financial affairs in order prior to being admitted to a skilled nursing facility so that they secure Medicaid benefits as soon as they exhaust their insurance coverage or private resources. Anyone in the long-term care industry knows, however, that many residents are unable to secure the Medicaid start-date that they need, which leaves the resident – and their provider – with unpaid bills for services rendered prior to their Medicaid eligibility.

Medicaid is a cooperative Federal and State program intended to assist needy and indigent individuals with the costs of care. In order to receive federal funding, State plans for Medicaid must comply with Federal requirements. The Centers for Medicare and Medicaid Services (“CMS”) has long interpreted unpaid expenses incurred prior to Medicaid approval as “not covered” under the State plan for Medicaid. As a result, Federal law requires State Medicaid programs to deduct unpaid medical expenses incurred prior to Medicaid eligibility when determining the amount of income that a resident is required to contribute toward the cost of his or her care; this amount is known as a resident’s “Cost Share” or “Patient Pay Liability.” In other words, Federal law provides Medicaid recipients the ability to apply their Cost Share/Patient Pay Liability towards uncovered pre-eligibility medical expenses. States are permitted to impose reasonable restrictions and many states have done so – allowing deductions, for example, only for uncovered medical expenses incurred three months (or, in some states, six months) prior to the month of the Medicaid application. Some states have elected to impose no time restrictions and allow for deductions in Cost Share/Patient Pay Liability for uncovered medical expenses regardless of when the expenses were incurred prior to the month of the Medicaid application.

In response to the COVID-19 pandemic, the governors of Illinois and Michigan have issue Executive Orders prohibiting long-term care providers from involuntarily discharging resident’s for non-payment. Other states, such as New York, are under pressure to pass similar prohibitions.

Pursuant to Illinois Executive Order 2020-35, Section 14, the provisions of the Nursing Home Care Act, 210 ILCS 45/3-401(d), MC/DD Act, 210 ILCS 46/3-401, and ID/DD Community Care Act, 210 ILCS 47/3-401, permitting a long-term care facility to initiate an involuntary transfer or discharge of a resident for late payment or nonpayment, is suspended. Full text available here.

Facilities face supply chain disruptions and staffing shortages

Faced with a global pandemic now affecting everyday life across the country, the U.S. healthcare system is struggling to cope with potential staffing shortages and supply chain disruptions.

“Everybody is stressed,” said Bill McGinley, President and CEO of the American College of Healthcare Administrators, or ACHCA. “Most of the stress is coming from the conflicting information put out by the CDC, CMS and various state agencies. Often it is conflicting and changes from day to day. It is very hard to keep up.”

Stotler Hayes Group Attorney, Nathan Peters, presented at the Texas Healthcare Association’s Board of Directors meeting on August 21st, 2019. Nathan shared two updates on how Stotler Hayes Group’s (SHG) Texas-based attorneys are successfully fighting to recover every Medicaid dollar available for our clients, and all Texas providers. SHG attorneys have litigated two major issues with the Texas Health and Human Services Commission (THHSC) and both could significantly impact future Medicaid payments in Texas. The issues the cases have dealt with include (1) the THHSC’s denial of an application for failing to exclude inaccessible resources for incapacitated Medicaid Applicants and (2) THHSC’s improper restrictions on Incurred Medical Expenses (IME). By some estimates, the IME payments could alone boost Medicaid provider payments over $40 million annually.

Unlike some state Medicaid agencies, THHSC previously refusing to exclude certain resources when reviewing Medicaid applications for incapacitated individuals. This policy is leading to a significant loss in payments for providers, because affected providers are left without a payor source until the incapacitated resident can secure a guardian with the authority to spend down their resources. Unfortunately for these providers, securing a guardian and spending down resources for incapacitated individuals is often a lengthy and complicated process. However, SHG’s recent victory in the case of Tex. HHS Comm’n v. Marroney, 2019 Tex. App. LEXIS 4298, 2019 WL 2237885 (Tex. App. – Austin May 24, 2019, Pet. Denied) should lead the THHSC to change its policy and start excluding inaccessible resources for incapacitated residents.

Deadline Looming for Mandatory Nursing Home Compliance Programs

Skilled Nursing Facilities have until November 28, 2019 to adopt and implement a compliance program that meets the elements set out by the Center for Medicare and Medicaid Services (CMS). Beginning on that date, state survey agencies will start assessing nursing homes’ compliance programs as an additional condition of participation in Medicare and Medicaid. Issued in 2016 as part of CMS’s revised Part 483 of Title 42 (“Requirements for States and Long Term Care Facilities”), the CMS compliance program elements are functionally identical to those from the Office of Inspector General for Health and Human Services (OIG).¹ Already the standard for effective compliance programs, the OIG elements are used to measure an organization’s culpability when federal fraud and abuse laws are violated. Specifically, the OIG considers “the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative sanctions.”

Care is at the heart of your mission and our nurses know too well the struggles of preserving a culture committed to caregivers. It isn't just about staffing—it’s about supporting. From our nurses to yours a series dedicated to compassionate care.