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centers-for-medicaid-and-medicare-services-and-snf-regulation
The document discusses the Centers for Medicare & Medicaid Services (CMS) and its role in regulating skilled nursing facilities (SNF). CMS oversees 100 million people through Medicare and Medicaid and works to improve healthcare quality while reducing costs. It regulates SNFs to increase provider performance and the quality of care delivered. Regulating SNFs gives consumers advantages like more accountability and quality standards, while giving providers incentives to improve care. CMS regulation of SNFs affects consumer choice in the healthcare marketplace.
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centers-for-medicaid-and-medicare-services-and-snf-regulation
- 1. Government Regulatory Agenciesand the Impact on Consumer Choices Team “C” HCS/490 Dan Crawley
- 2. Centers for Medicare& Medicaid Services This Presentation Will Examine The Following: •Roles and Responsibilities •The Health Care Products & Services the Agency is Accountable for Managing or Regulating. •Overview of Skilled Nursing Facilities (SNF) •How the Agency Oversees, Governs, & Regulates Skilled Nursing Facilities. •Advantages of this Control to the Consumer •Advantages of this Control to the Provider •The Role of the Agency and it’s Regulation of Skilled Nursing Facilities, & the Affect of Consumer Choice in the Health Care Marketplace. •Consumer Health Care Costs •Related factors that Contribute to the Consumer’s Choice of Providers.
- 3. Centers for Medicare& Medicaid Services Roles, Responsibilities, & Regulations Image Credit: www.eventbrite.com CMS covers 100 million people through Medicare & Medicaid. CMS Strives to increase the health of Americans while reducing costs. CMS enforces and implements health care legislation CMS reduces fraud, waste, and abuse of federal health programs.
- 4. The Health CareProducts & Services the CMS is Accountable for Managing or Regulating Image Credit:www.medicare.gov Image Credit:blogs.browardpalmbeach.com
- 5. Overview of SkilledNursing Facilities (SNF) Image Credit: Bayoupines.com A Skilled Nursing Facility (SNF) is a 24 hour health care facility that provides skilled nursing care to patients in need.
- 6. How CMS Regulates Skilled Nursing Facilities Image obtained from: www.chandler-glendale.com
- 7. Advantages of CMSControl to the Consumer Image 1 obtained from: xeloq.wordpress.com Image 2 obtained from: www.goldsmithinsurance.com Image 3 obtained from: aumpt.co
- 8. Advantages of CMSControl to the Provider Image 1 obtained from: manifestedharmony.com Image 2 obtained from: www.newhopebaptistchurch-wc.comi Image 3 obtained from: www.montecookgames.com
- 9. CMS Skilled NursingFacility Regulation & The effect of Consumer Choice in the Health Care Marketplace. Overall, CMS’s regulation of SNF providers increases provider efforts and performance therefore bettering the quality of care delivered. In the event a provider’s loses CMS certification it significantly reduces their potential consumer base and removes the potential 100 million Medicare and Medicaid beneficiaries from its desired demographic.
- 10. Consumer Health CareCosts
- 11. Related factors thatContribute to the Consumer’s Choice of Providers.
- 12. Conclusion Image obtainedfrom: www.piperreport.com
- 13. Reference Bowers, L.(2013). Long Term Living. Medicare.gov. Retrieved from http://www.ltlmagazine.com/news-item/private-snf-care-tops-94k-year-insurance-survey- says Center for Medicare & Medicaid Services (n.d.). Criteria for Long-term Care Services: Skilled Nursing Facility Services. Retrieved from http://www.dhos.ca.gov/services/medi-cal/Documents/ManCriteria_26_LTC.htm Center for Medicare & Medicaid Service (2013). Details for Title: New resources available to Help consumers navigate the health insurance marketplace Retrieved from http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press- Release/2013-Press-Release-Itmes/2013-08-15.htm Centers for Medicaid & Medicare Service. (2010). Medicare and Home Health Care. Retrieved from http://www.medicare.gov/pubs/pdf/10969.pdf
- 14. Reference Center forMedicare and Medicaid Services. (n.d). Skilled Nursing Facility PPS . Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/index.html Center for Medicare & Medicaid Services (2012). Skilled Nursing Facility Prospective Payment System: Payment System Facts Sheet Series. Retrieved from http://www.cms.gov.Outreach-and-Education/Medicare-Learning-Network- MNL/MNLProducts/downloads/snfpropaymtfctsht.pdf Illinois Department of Public Health. (n.d.). Nursing Homes in Illinois. Retrieved from http://www.idph.state.il.us/healthca/nhregulate.htm Kotler, P., Shalowitz, J., & Stevens, R. J. (2008). Strategic marketing for health care organizations: Building a customer-driven health system. San Francisco, CA: Jossey-Bass. Medicare.gov. (2013). Medicare.gov The Official U.S. Government site for Medicare. Retrieved from http://www.medicare.gov/coverage/skilled-nursing-facility-care. html
Editor's Notes
- #3 In this presentation, Team C will explore the Centers for Medicare and Medicaid Services and how this agency’s regulation of skilled nursing facilities impacts consumer choices. This presentation will cover the roles and responsibilities of CMS. We will discuss the various products and services that CMS is accountable to provide the oversight and regulation for. This presentation will further assess CMS regulation with the detailed look into management and oversight of skilled nursing care and the facilities that provide it. The team will illustrate how the CMS agency oversees, governs, & regulates skilled nursing facilities. We will review the advantages of CMS control and regulation of SNF to the Consumer; in addition to the advantages of CMS monitoring for the SNF provider. The presentation will demonstrate the role CMS’s regulation of Skilled Nursing Facilities, and the effect it has on provider choice and the skilled nursing care marketplace. We will also touch on the cost of SNF care to the consumer, and how CMS works to lower these costs.
- #4 The Centers for Medicare and Medicaid Services (CMS) was previously known as the Health Care Finance Administration (HCFA) CMS is a division of the Department of Health and Human Services (DHHS) and works in partnership with state governments to finance, provide, and administer federally funded health insurance programs including Medicare, Medicaid, and the States Children’s health plan (SCHIP). In 1965 president Lyndon B. Johnson was at a ceremony to honor the former president Truman leadership on health insurance that he begin to offer in 1945. The Medicare and Medicaid programs were signed into the law on July 30th, 1965. In the president’s speech he stated that approximately all eligible American seniors will receive hospital care and this is to also be considered an act of assistance, but as the protected right of the senior citizen. Also, it remained to succeed if the health care providers accept the responsibility to not discriminate against anybody race because it is the law. So doing the first year of the Medicare program being a success it helped fulfill the promise, that the elderly can be free from worrying about hardships of sickness because of financial issues. The Federal Government and CMS are responsible for the control and administration of Medicare and Medicaid services. CMS partners with other organizations within the U.S. Department of Health and Human Services to manage these public insurance programs; along with the enforcement and implementation several other health related laws and regulations. CMS started to regulate skilled nursing facilities because of the regulations in the criteria. Skilled nursing facilities are part of the federal certification criteria for nursing homes. Centers of Medicare and Medicaid started to regulate skilled nursing facilities to also help with how these facilities are getting paid by Medicare and Medicaid. "Section 4432(a) of the BBA of 1997 modified how payments are made for any Medicare skilled nursing facilities. SNF goes from being paid for a reasonable cost basis or low volume prospectively determined rates. Now they are getting paid by on the basics of prospective payment systems of (PPS)" (CMS, n.d)
- #5 CMS has three central goals which include 1) improve the life of patients, 2) improve overall health of communities, and lower health care costs. A large requirement in achieving these goals includes reducing fraud, waste, and abuse of its services. CMS administers Medicare and Medicaid services to beneficiaries that qualify, and funds these programs with federal dollars allocated to the states. “Diagnosis related groups (DRGs) have been developed by the Centers for Medicare and Medicaid Services (CMS) in order to reimburse hospitals for inpatient stays through the Medicare program” (Kotler, Shalowitz, & Stevens, 2008). The CMS also enforces various legislations related to health care including the Health Insurance Privacy and Portability Act (HIPPA), the Clinical Laboratory Improvement Amendment (CLIA), Emergency Medical Treatment and Labor Act (EMTALA), and the Electronic Health Record (EHR) Incentive Program. (CMS.gov, 2013) They execute Health Care Reform laws as well in addition to many cost reducing efforts. Furthermore, CMS evaluates, polices, and regulates skilled nursing facilities to ensure a standard of quality care for consumers. CMS also is involved in reducing health care costs, improving efficiency and accuracy in the billing process, reducing fraud waste and abuse of the Medicare and Medicaid program services, monitoring laboratory safety and ensuring pharmaceuticals are properly stored, administered, and documented. This is just a few of the responsibilities of the agency, and they all seem to tie into skilled nursing performance and provider accountability. Without this agency, the Medicare and Medicaid programs would be out of funding, and many hospitals and nursing homes would not be held accountable for issues that can only be acquired from poor care like hospital acquired infections, bed sores, and other forms of neglect.
- #6 A Skilled Nursing Facility (SNF) is a 24 hour health care providing facility. The SNF will provide constant care for patients who are admitted for a short term or long term basis. SNF patients are typically elderly, disabled, mentally ill, or in need of rehabilitation for a variety of conditions. If a patient needs long term custodial care or short term rehabilitation services a SNF nursing home, rehab center, or hospital with a “swing bed policy” are the providers of care. CMS along with state agencies monitor SNF providers and ensure compliance with their imposed standards of care. CMS also regulates alternatives to SNF such as Home Health Agencies, Assisted Living Facilities, and Personal Care Homes with similar evaluation and monitoring procedures. Nursing is a profession that has evolved dramatically over the years, yet the need to provide skilled nursing care for the elderly and disabled has not changed. Nursing Homes are commonly low paying employers that offer little or no benefits for the employees. The tasks and duties are very repetitive and can cause great care staff to become burnt out. Additionally, staffing shortages and high turnaround rates can lead to hiring staff that are not empathetic enough to provide quality care to residents. Whatever the real reason, the elderly and disabled are often the victim of abuse, neglect, theft, and even fraud on behalf of the care facility. Therefore, skilled nursing facilities must be under strict regulation by local and federal governments to combat the issues and hold people accountable.
- #7 “Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs”(CMS.gov, 2013). This means that if a SNF provider wants to receive patients who have Medicare or Medicaid coverage, they must follow all rules and submit to an inspection and survey by CMS and state agencies annually or at the time of complaint. “To certify a SNF or NF, a state surveyor completes at least one Life Safety Code (LSC) survey and one Standard Survey annually” (CMS.gov, 2013). However, when deficiencies are found, these surveys turn into investigations requiring provider action to correct any issues found. “Skilled nursing facilities are licensed, regulated, and certified by a number of agencies at both the state and federal levels, including the state Department of Public Health, the Department of Health and Human Services’(DHHS) and the Centers for Medicare and Medicaid Services (CMS)”( Illinois Department of Public Health, n.d.). This is in addition to the local and state regulating agencies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Department of Aging and Disability Services (DADS), all these agencies have separate, but intersecting dominions of control concerning SNF care and provision” (Illinois Department of Public Health, n.d.). CMS also publishes a five star quality rating system on certified SNF providers, rating their performance and ability to provide high quality care. “If a SNF provider receives a deficiency on an evaluation survey, depending on the nature of the problem, CMS can take penalizing action against the nursing home” Medicare.gov, 2013). CMS has many options when it comes to reprimanding deficient facilities. “CMS can impose a large fine, deny payment, assign a temporary manager, or install a State monitor” (Medicare.gov, 2013). In the event a SNF provider chooses to ignore or is unable to the correct its complications or violations, CMS subsequently terminates its certification contract with the SNF provider.
- #8 CMS is a an ethical organization with the well being of its clients at heart. CMS works very hard to provide benefits to the consumer, these benefits include, but are not limited to: 1.CMS strives to reduce fraud, waste, and abuse of its services and of the consumer. 2.CMS provides low cost or no cost health care benefits for qualified consumers. 3.CMS sets a standard of quality care for consumers and ensures providers are held
- #9 1. Providers can assure that they will receive payment in accordance with Medicare and Medicaid standards. If a consumer has Medicare plus another healthcare coverage from an additional insurance company (payers), then the provider can and will receive the payment regardless. Providers have a right to bill Medicare when the primary payer has not paid usually within 120 days. (Medicare.gov, 2013). 2. Providers can add quality of care and include the five star rating results to patients tgat are seeking care in a skilled nursing facility. Can allow the opportunity for questionnaires to be done, so that it can help them better serve the patient. Providers can use the positive survey results as a selling point to potential consumers. For example providers can share and celebrate that the facility has had no deficiency on investigations for “x” amout of years.
- #10 CMS’s regulation of SNF providers, is bound to increase their effort to health promotion, and measurement of health care quality performance through new development of health services or product primarily health insurance in the marketplace. CMS works to reduce fraud, waste, and abuse in order to lower health care costs and lessen the 8 billion dollar a year price tag Medicare has on the economy. When a provider’s certification is denied or terminated it in turn significantly reduces their potential consumer base and removes the 100 million Medicare and Medicaid beneficiaries from its intended demographic.
- #11 SNF care is costly, and coverage can vary by insurance provider. According to Long Term Living, Lois Bowers evaluated a survey about the cost of skilled nursing to the consumer annually. “The survey established the typical cost of SNF care in the United States is $94,170 a year ($258 a day) for a private room in a nursing home, $82,855 a year ($227 a day) for a semi-private room in a nursing home, $41,124 a year ($3,427 a month) for an assisted living facility and $18,460 for adult day care, the average cost for care provided in a home setting was about $29,640” (Bowers, 2013). SNF care can be divided between short term stays and long term stays. Medicare does not cover long term stays in a SNF facility, yet “Part A subscribers with a qualifying physician order or hospital stay have no cost out of pocket if the stay is less than 20 days. From 21 to 100 days SNF care is covered with the patient responsibility falling at 148.00 per day, and over 100 days the patient is responsible for all SNF costs” (Medicare.Gov, 2013). Medicaid covers long term care and short term care, as well as pays significant amounts of these costs when the qualified patient is approved for coverage.
- #12 SNF facilities must be CMS certified to accept Medicare and Medicaid covered patients, which limits the facilities available for the patient to choose from. If no certified facilities are available, hospitals can provide swing bed SNF coverage and care for patients.
- #13 In conclusion, the Centers for Medicare and Medicaid Services regulate and impacts skilled nursing facilities and consumer choices. CMS has several essential roles and responsibilities including administering federally funded insurance programs, regulating skilled nursing care, and reducing fraud, waste, and abuse of services. CMS is accountable to provide the oversight and regulation for various products and services in the health care market. CMS is in authority of the governmental management and oversight of skilled nursing care and the facilities that provide it. We have reviewed the advantages of CMS cost control and regulation of SNF for the Consumer; in addition to the advantages of CMS monitoring for the SNF provider. CMS does have a significant effect on provider choice for skilled nursing care in the marketplace, as well as provide a quality standard of care for the consumer.