The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Compliance Matters Post Go-Live
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The Skilled Nursing Facility (SNF) industry has faced disruption with Medicare Part A’s transition to the Patient Driven Payment Model (PDPM) in the fall of 2019. Providers seeking additional guidance to further develop and shape their compliance programs are encouraged to view the presentation given by join PYA at the AHLA Long Term Care and the Law program in March of 2020. PYA Post-Acute Service Line Manager Amy Dalton co-presented with Liz Steffen, MJ CHC CPHRM MBA HCM MA CCC-SLP, Senior Divisional Corporate Compliance Officer of Promedica Health System. “The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Compliance Matters Post Go-Live” covers the following topics: • Trends in care provision related to value-based outcomes and quality of care. • Relevant compliance updates from the Department of Health and Human Services, Department of Justice, and Office of Inspector General. • Clinical operational and compliance-related hurdles for SNFs post-PDPM go-live. • How PDPM fits into the larger context of a SNF compliance program. • PDPM recommendations and best practices going forward.
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The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Compliance Matters Post Go-Live
- 1. The PPS to PDPM Pendulum: An Analysis of PDPM Compliance Matters Post Go-Live
- 2. Speaker Information Liz Steffen MJ CHC CPHRM MBA-HCM MA CCC-SLP Promedica Health System Senior Divisional Corporate Compliance Officer Direct: 419.252.5536 Amy Dalton, LNA P.Y.A., P.C. Post-Acute Service Line Manager Direct: 727.669.2930
- 3. Disclaimer The contents of this presentation are intended to convey general information only and not to provide legal advice or opinions. The contents should not be construed as, or relied upon for, legal advice in any particular circumstance or fact situation. The information presented may not reflect the most current legal developments. No action should be taken in reliance on informational content, and we disclaim all liability in respect to actions taken or not taken based on any or all of the content. An attorney should be contacted for advice on specific legal issues.
- 4. Agenda • Industry Trends • Transition Hurdles • Compliance Program Requirements • Federal Guidance • PDPM Compliance Risk Considerations • Recommendations • Resources
- 5. Learning Objectives Trends in care provision related to value-based outcomes/quality of care Clinical and operational-related hurdles for skilled nursing facilities PDPM go-live How PDPM fits into the larger context of a SNF Compliance Program Relevant compliance updates from DHHS, DOJ, and OIG PDPM recommendations and best practices going forward Recommendations Resources
- 7. Reimbursement Considerations • Budget Neutral Payment System1 – CMS intended for the total estimated payments under PDPM (FY2020) to be equal to the total actual payments under RUG-IV (FY2019) • Reimbursement rates: PDPM vs. RUG-IV – RUG-IV - $560 – PDPM - $615 1 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2020
- 8. Reimbursement Considerations • Future rate recalibration and audits • FFS Medicare continues to lose ground as the base for other payer sources
- 9. Therapy Strategies • Modes of therapy: • Therapist understanding of individual/group/concurrent definitions • Programming enhancements for maximizing patient benefits of group • Identify opportunities for efficiencies with potential cost savings • Contracted Therapy Partners • Transition from contracted to in-house therapy • Review contracts and compare to daily rates • Reduction in Workforce • Implications with Payroll-Based Journal reporting Steffen, L. (2019). Intensive Rehabilitation for Post Acute Rehabilitation Services: The Impact of Value-Based Regulatory Change on Service Delivery. Journal of Health Care Finance.
- 10. Therapy Strategies • Specialty Service Offerings • Ensure clinician skills/services/programming target higher-acuity patients • Harnessing the Interdisciplinary Team • Bridging the nursing/therapy gap • “Freedom” for therapists based on patient needs • Emphasis on interdisciplinary care plans tailored to resident needs • Speech therapy/dietician collaboration Steffen, L. (2019). Intensive Rehabilitation for Post Acute Rehabilitation Services: The Impact of Value-Based Regulatory Change on Service Delivery. Journal of Health Care Finance.
- 11. Outcomes and Quality Measures • Correlation of Therapy Minutes and Outcomes • Push for providers to standardize care, correlating outcomes with diagnosis and therapy minutes/services provision • Use of Group and Concurrent Therapy • Monitor 25% threshold • Identify risk factors for injury or rehospitalization and determine appropriate length of stay
- 12. PPS RUV-IV to PDPM Transition Hurdles
- 13. Transition Hurdles • Coding and documentation • Acute/Post-acute hand-off • Education to ensure documentation is individualized, skilled, and medically necessary • Allow for the accurate codes to capture all patient characteristics, comorbidities • Alignment of care planning and patient goals • Streamlining section “GG” with detailed interdisciplinary documentation
- 14. Transition Hurdles • Ongoing training of interdisciplinary clinical team • Shifts in therapy delivery and utilizing group and concurrent modalities and increase in acuity capability • Potential revenue cycle and back office challenges • Consistency among multi-facility organizations • Harnessing education, accuracy, and learning improvements across multi-facility organizations
- 15. Transition Hurdles • Comprehensive Person-Centered Care Planning §483.21 • Baseline care plan within 48 hours of admission (weekend and holiday included) • Should balance immediate needs risks of patient’s health and safety concerns to prevent decline and/or injury • Patient must receive a written summary of the Baseline Care Plan
- 16. Skilled Nursing Facility Compliance & Ethics Program Requirements
- 17. Compliance Program 1970s and 1980s high profile corporate fraud or misconduct 1990 United States Sentencing Commission Federal Sentencing Guidelines
- 18. Elements of Effective Compliance Program • Implementing written policies, procedures, and standards of conduct • Designating a compliance officer and committee • Conducting effective training and education • Developing effective lines of communication • Enforcing standards through disciplinary guidelines • Conducting internal monitoring and auditing • Responding promptly to detected offences and undertaking corrective action https://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf
- 19. 2000 2008 2010 2015 2016 2017 2019 2000: OIG Compliance Program Guidance for Nursing Facilities (65 FR 14289) – Voluntary 2008: OIG Supplemental Compliance Program Guidance for Nursing Facilities (73 FR 56832) – Voluntary 2010: Affordable Care Act 6102, Outlines Specific Provisions for SNF compliance program 2015: CMS, HHS Proposed rules for nursing facilities (80 FR 42167) 2016: CMS HHS Final rules for nursing facilities Phase 1 (81 FR 68688) 2017: Mandatory compliance by November 28, 2019 Phase 2 (81 FR 6868) Delayed enforcement 18 months 2019: MANDATORY Phase 3 Compliance & Ethics program November 28, 2019 (81 FR 68688)* SNF Compliance & Ethics Program Timeline *CMS Proposed 1-year Delay & Modification of certain Elements; July 2019 however currently remains proposed status
- 20. 42 CFR 483.85 • November 28, 2019: Nursing facilities must have in operation an EFFECTIVE compliance and ethics program for each facility • Prevent and detect criminal, civil, and administrative violations • Promote quality of care per regulations • “Effectiveness” • HCCA-OIG Measuring Compliance Program Resource Guide • United States Sentencing Guidelines, 8B2.1 2009 42 CFR 483.85 https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf
- 21. 42 CFR 483.85 • As part of Requirements of Participation (RoP) – Phase Three - surveyors may issue citations for failure to have the required compliance program in place via F Tag: F 895 however: • Currently awaiting CMS interpretation guidance, anticipate Q2 2020 • AHCA encourages review of 483.85 to ensure accurate changes are put in place • CMS issued PROPOSED delay and revisions however remains PROPOSED https://www.ahcancal.org/facility_operations/integrity/Pages/Compliance-Programs.aspx
- 22. 42 CFR 483.85 • Compliance program extends to: • Operating organization entire staff • Vendors or individuals performing services under contractual arrangements • Volunteers, consistent with expected roles 42 CFR 483.85
- 23. Additional Regulatory Requirements Organizations with >5 Facilities • Annual training 483.85(f), Annual Review • A Designated SNF Compliance Officer 483.85(c) (2) • High level in the organization • Has sufficient resources and authority • Who reports directly to the board – No layers • Does NOT report up through general counsel or CFO or COO • Compliance liaison at each of the operating facility locations 483.85 (d) (3)
- 24. Auditing & Monitoring • Expects audits focusing on financial records, quality of care • Further violation prevention, process modification, ongoing monitoring determination • Vicarious liability • “Knew or should have known” standard
- 25. 60-Day Repayment Rule: Medicare Parts A & B • Duty to investigate • Exercise reasonable diligence • Proactive and reactive investigations • Establish a six-year lookback period • Quantify amount of overpayment • Failure to report and return creates liability under FCA • Work product doctrine/Attorney Client Privilege considerations False Claims Act, 31 U.S.C. 3729 Affordable Care Act, Section 1128J(d) Social Security Act 81 Fed. Reg. 7654, Published February 12, 2016
- 26. 60-Day Repayment Rule Medicare Parts A & B • 60-day reporting/returning begins when either: • Reasonable diligence is completed OR • The day the provider received credible information of a potential overpayment • Timely is typically a 6-month period from receipt of credible information of an overpayment • 8 months generally maximum total time for return False Claims Act, 31 U.S.C. 3729 Affordable Care Act, Section 1128J(d) Social Security Act 81 Fed. Reg. 7654, Published February 12, 2016
- 27. Federal Guidance
- 28. DOJ Compliance Guidance DOJ Compliance Guidance (2017) DOJ Compliance Guidance (2019) Prior Knowledge Well-Designed Proactive Reflect Risk of the Industry Utilizing Resources Applied Earnestly & Good Faith Root Cause Analysis Work in Practice Effective Response Proactive https://www.justice.gov/criminal-fraud/page/file/937501/download
- 29. OIG Compliance Guidance OIG Compliance Guidance (2000) 65 FR 14292 OIG Supplemental Guidance (2008) 73 FR 56833 Quality of Care Quality of Care Record Keeping & Documentation Submission of Accurate Claims Employee Screening Employing/Contracting Excluded Individuals Vendor Relationships Physician Self-Referrals (Stark) 42 C.F.R. 411.350-411.389 Billing & Cost Reporting Anti-Kickback Statute, Inducements 42 U.S.C. 1320a-7b Residents’ Rights HIPAA Privacy & Security
- 30. Quality of Care • Addressing quality and sub-standard care in SNFs has remained an ACTIVE item on the DHHS OIG Workplan • Elder Abuse Prevention & Prosecution Act, 2017 https://oig.hhs.gov/reports-and- publications/workplan/summary/wp-summary-0000140.asp
- 31. Quality of Care • Staffing • Comprehensive Resident Care plans • Medication Management • Resident Safety • Use of Psychotropic Medications • Staff Screening https://www.medicare.gov/nursinghomecompare/About/howcannhchelp.html
- 32. Quality of Care • Services that have repeatedly been deemed sub-standard (as evidenced by repeated deficiencies), has arguably submitted false claims in theory https://www.congress.gov/115/plaws/publ70/PLAW-115publ70.pdf
- 35. Quality • Length of Stay (LOS) • Early Discharge or Fewer Services • Skilled, Medically Necessary Services • Resident Interviews • Documentation, Care Plans • Assessment and Changes in Condition
- 36. Quality • Depression (D) • Psychological/Psychiatric Services • Psychotropic Medication • Care Plans • Mechanically Altered Diets, Swallowing Disorders (K) • Speech Language Pathology Services • Dietician Services • Care Plans
- 37. Quality Recommendations • Coordinate efforts with QAPI Program/Facility Assessment • Align quality oversight function with bridge to compliance • Ensure open lines of communication • TeamSTEPPS© Considerations • Ensure audit of abuse, neglect reporting and timeliness • Monitor QRP & VBP Monitoring PDPM Transition Performance
- 38. Therapy Operations • RUG-IV v. PDPM Comparison • Intensity: Under Utilization, Access • Maintenance Therapy • PDPM Preference Skilled Nursing v. Skilled Therapy • Jimmo v. Sebellius Settlement Considerations • Functional Scoring (GG) Accuracy • Modes of Therapy Delivery (O) • Therapy Contracts https://www.medicareadvocacy.org/medicare-info/improvement-standard/
- 39. Therapy Recommendations • Evidenced-based care practice • MDS Scoring/Therapy Documentation Alignment • GG Scoring Translation - Functional levels • Ensure all components captured on MDS are incorporated into therapy treatment plan • Monitoring of Modes • Hugging the 25% group/concurrent limit will be monitored; could be the new “hugging the RUG”
- 40. MDS 3.0 • Daily Skilled Coverage • Interim Payment Assessment (IPA) • Expected to be infrequent • +/- CMGs • Interrupted Stays • Over-use, restart variable per diem • CMS error, identified workaround • UB04 and MDS Alignment
- 41. MDS 3.0 Recommendations • IPA tracking • CMG changes via IPA must have supporting clinical documentation • Interrupted stay P&P, tracking • Increase visibility MDS coordinator, team/patient involvement • Ensure to incorporate risk assessment, audit, and ongoing monitoring controls
- 42. Coding • ICD-10-CM Coding Accuracy • Primary Diagnosis Code • Comorbidity Diagnosis • Non-Therapy Ancillary • Health Insurance Prospective Payment System (HIPPS) Coding • Crosswalk Accuracy
- 43. Coding Recommendations • Admission processes are critical • Educate upstream/downstream relationships • Ensure patient-focused relationships – handoffs • Enhance physician communication • Ensure established audit and ongoing monitoring controls
- 44. Recommendations
- 45. Best Practices • Compliance program has seven elements and meets federal requirements • Annual documented program review and revision • Ensure PDPM risks are included in the compliance program work plan • Ensure facility-level awareness, education, and engagement
- 46. Best Practices • Conducting Risk Assessment • OIG Workplan • Recent national settlements • Individual facility history • Quality of care • Survey history • Overpayment history • Auditing and monitoring
- 47. Best Practices • Update Auditing and Monitoring Systems • Periodic audits must incorporate financial records and quality of care • Accurate determination assessment of ongoing monitoring – ensure there is education and follow up • Alignment of quality and compliance efforts
- 53. References • Compliance and Ethics Program Rule, 42 CFR 483.85 • OIG Compliance Program Guidance, 65 FR 14289 • OIG Supplemental Compliance Program Guidance for Nursing Facilities, 73 FR 56832 • CMS, Nursing Home Toolkit: Program Integrity and Quality of Care – An Overview for Nursing Home Providers
- 54. Questions?