focus on financials final presentation...section 4432 of the balanced budget act of 1997 (bba, pub....

RSBM Training‐ Focus on Financials: April 26, 2017

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Georgia State Office of Rural Health & HomeTown Health, LLCWelcome you to the:

This project is supported by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) grant number 16062G.

2016-2017 Rural Swing Bed Management (RSBM) Training Program

Focus on Financials

Best Practices for Compliance & Efficiency

Continuing Education Unit ConditionsAs an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health,LLC is authorized by IACET to offer 0.3 CEUs/3 Credit Hours for this Session.

This educational offering has been approved by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) to provide 3.0 clock hours/3.0 participant hours.

Learning Outcome ConditionsIn order to obtain credits for this conference, attendees must:1. Attend all presentations; sign in on the sign in sheet.2. Submit the CEU Request Form at the end of the meeting. Be sure to provide a valid email address.3. Complete an online exam with an 80% or better.4. Complete the online program evaluation.

After confirming you have met all minimum attendance requirements, Evelyn Leadbetter will email you a link to the program assessment and evaluation required to receive your CEU Credit Certificate and Transcript.

Questions about CEUs? Please contact Evelyn Leadbetter at [email protected].

AGENDATime Topic

10:00 am – 10:05 am Introduction of Kerry Dunning & “Focus on Financials”

10:05 am – 10:35 am Rule Number 1 – Stay our of Trouble

10:35 am – Noon Evaluating Your Program

12:00 pm – 12:15 pm Break – Bring Lunch back for final hour

12:15 pm – 1:15 pm Focus on Tracking, Training & Growth

Swing bed programs can improve occupancy and productivity in addition to increasing facility revenue. However, swing bed programs will do more harm than good if hospital leadership do not understand very specific skilled nursing regulations. The ability to utilize swing beds increases revenues and margins that canhelp support population health, wellness, and other services. Kerry Dunning will provide training and resources in order to help financial hospital staff & leaders to increase utilization and revenue for post-acute care services, as well as ensure compliance in financial matters related to program management.


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RSBM Program TrainerKerry Dunning LLC

• Ms. Dunning has 20 years in health care consulting and over 30 years in the industry. • She specializes in the post-acute market working with hospital based skilled nursing

and swing bed programs, critical access hospitals, freestanding skilled facilities, inpatient/outpatient rehab programs, inner city teaching hospitals and rural health care systems.

• Ms. Dunning worked for HCA and HealthTrust hospitals in administrative roles; Horizon Rehabilitation and ServiceMaster Rehabilitation as a Sr. Vice President and Chief Operating Officer; with GPS Healthcare as the Chief Senior Services Officer; and has spent more than 20 years as an independent consultant.

• In addition to serving as an Adjunct Instructor in the College of Health at the University of North Florida, Ms. Dunning regularly leads workshops and webinars regarding Medicare, skilled nursing (including MDS), swing bed programming, and reimbursement cycle improvement. She also works on international health care projects and research.

• Her favorite job is on-site helping facilities take better care of patients.

Kerry Dunning has no proprietary interest in any product, instrument, device, service, or material discussed during this learning event.

The education offered by Kerry Dunning, LLC in this program is compensated by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) under grant number 16062G.

Based upon Center for Medicare and Medicaid (CMS) Swing Bed Providers guidelines, Georgia State Office of Rural Health identified needs, and hospital based skilled nursing and swing bed program best practices, participants will be able to:

1. Recognize the basic audit targets, coding risks and how to set up double checks

2. Identify opportunities for census growth, revenue enhancement, and staff productivity

3. Focus on tracking key monitors and using information for revenue growth and protection


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Swing beds must follow skilled nursing guidelines but the rules are not always well defined.

PPS swing beds must provide understand Medicare intent, reimbursement and medical necessity and documentation

CAH swing beds must be vigilant in understanding Medicare intent, medical necessity documentation, and achieving measurable outcomes

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Lower Acute/Other use for Beds Additional revenue source◦ Consider more Medically Complex admissions

Staffing Productivity Community need/Physician billing

BUT Must be managed closely Not used as “acute” Staff educated Admissions criteria clear Control cost

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Section One


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1. How are your coders aware of primary services used in skilled nursing?

2. If you are a PPS SWB, do your billers get a copy of the validation report?

3. When is the 3-midnight rule still in play?4. Do you allow LOAs? How do you bill for LOAs?5. What services should not occur in a swing bed?6. When are swing bed claims submitted?7. How are you tracking outcomes? Trends? Cost?

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Medicare A and days available 3 Midnight rule (if applicable) Meet skilled criteria and Admissions criteria◦ Not meant to be a Medicaid program

Admissions process and change in level of care MSP Physician Certification Therapy POC signed/dated by physician timely NOMNC Billing AFTER information is verified◦ PPS: validation report

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1. Patient requires skilled services on a daily basis (§30.6)

2. As a practical matter, considering economy and efficiency, the daily skilled services can only be provided on an inpatient basis in a SNF (§30.7)

3. The services must be reasonable and necessary for the treatment of a patient’s illness or injury

4. The services must also be reasonable in terms of duration and quantity

5.

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The Nursing Home Reform Act mandates that nursing facilities use a clinical assessment tool known as the Resident Assessment Instrument (RAI) to identify residents’ strengths, weaknesses, preferences, and needs in key areas of functioning◦ The assessment is an integral part of the residents’ medical record◦ It is designed to thoroughly provide each resident with a standardized,

comprehensive, and reproducible resident assessment◦ Determines individualized care plans for each resident◦ The minimum data set (MDS) is a component of the resident

assessment which contains a standardized set of essential clinical and functional status measures

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The RUGs flow from the MDS and drive Medicare reimbursement to nursing homes

Residents are initially assigned to clinical, therapy or clinical + therapy categories◦ ADLs are a key driver of reimbursement◦ Therapy minutes are the primary patient types in SWBs Therapy Log

Understanding of minutes

Matching minutes to claim (PPS) or understanding what is medically necessary (CAH)

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CAH PPS

The SNF-level services provided by a CAH, are paid at 101% of reasonable cost. ◦ Hospitals must follow the rules for

payment in Medicare Claims Processing Manual §60 for swing-bed services.

Other elements:◦ Coinsurance and deductible are

applicable for inpatient CAH payment.◦ All items on the ASC X12 837

institutional claim format are completed in accord with the implementation guide applicable to the dates of the stay. All items on Form CMS-1450 are completed in accordance with Chapter 25.

Section 4432 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33, enacted on August 5, 1997) amended section 1888 of the Act to provide for the implementation of a per diem PPS for SNFs

Section 1883 of the Act permits certain rural hospitals to enter into a Medicare swing-bed agreement, in accordance with section 1888(e)(7) of the Act, these services furnished by non-CAH rural hospitals are paid under the SNF PPS

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Swing bed payment regulations can be found at 42 CFR 409.30. Standard (a) discusses discharge from the hospital.◦ Basically a SNF patient does not have to be from the same hospital or CAH as the swing

bed.◦ 42 CFR 482. 12(c)(4) defines that a physician is responsible for the care of the patient. ◦ 482.24(c)(2)(vii) states that all records must document a discharge summary with outcome

of hospitalization, disposition of care, and provisions for follow-up care. As the person responsible for the care of the patient it therefore follows the physician must do the discharge summary.

Discharge from the acute care hospital bed is required because the patient is changing from one form of reimbursement to another. ◦ This is a reimbursement requirement for payment. A swing bed is not considered hospital

level care. ◦ It is defined in the payment regulations as SNF level care and is reimbursed at a lesser

amount. It therefore follows that the patient must have a discharge summary following

acute care services. When the patient is discharged from the swing bed, they need a discharge summary of SNF level services.

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CAH Swing beds are exempt from SNF consolidated billing, however they do need to follow the direction in the CMS Internet Only Manual (IOM), Publication 100-4, Chapter 3, Section 10.4 on bundling hospital charges. These charges should be included on the 18X type of bill

Services provided by the CAH, while the beneficiary is inpatient in the CAH Swing bed that are considered exclusions from SNF Consolidated Billing, shall be billed on an 85X type of bill. All related outpatient charges shall be included on the 85X type of bill that would typically be billed for outpatient services.

As stated in the IOM, Publication 100-4, Chapter 3, Section 60, swing bed services must be billed separately from inpatient hospital services. Therefore, any swing bed patient who requires inpatient hospital services must be discharged from the swing bed and admitted as a hospital inpatient.

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Scenario: George, a Medicare patient, was in a covered swing bed stay receiving skilled nursing for complications related to a heart attack. During the stay, George began to complain of severe headaches, so the physician ordered a CT of the brain with and without contrast. After reviewing the exam, the physician determined the findings were normal and no additional treatment or skilled services were required, so the physician discharged George and he was free to go home. The CAH will bill the charges for the CT scan on an outpatient claim because the procedure is listed as one of the major categories for skilled nursing facility (SNF) consolidating billing.

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TRUE OR FALSE?


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False. Although the CT scan is considered a major category and is an “excluded” service under the SNF PPS consolidated billing requirements, CAHs are exempt from using the list and services provided while the patient is in a CAH’s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required. <Social Security Act §§ 1888(e)(7), 1883(b)(3), 42 CFR 413.114, MLN Matters SE0606>

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Section Two


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Patients should be encouraged to wear their personal clothes and participate in activities as appropriate

Admissions Criteria – not your mayor’s mother’s program

Care Plan and patient participation Hospitals policies can be used for much of a SWB

program:◦ Transfer policies◦ Elopement◦ Procedure for notification when a resident no longer qualifies

for swing beds

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The management of this plan of care requires skilled nursing personnel until such time as skilled care is no longer required in coordinating the patient’s treatment regimen The documentation in the medical record as a whole is

essential for this determination and must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the stabilization of the patient's medical condition and safety.

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Consistent with the symptoms or diagnoses of the illness or injury under treatment

Necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational)

Not furnished primarily for the convenience of the patient, the attending physician, or the family

Furnished at the most appropriate level that can be provided safely and effectively to the patient

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• Daily Documentation is required to reflect the skilled services being provided. – Objective measures of the current level of assistance

required for functional tasks– A description of the skilled services provided– Assessment of the patient's response to the services.– Progress towards the treatment goals– Documentation of any treatment variations with the

associated rationale– Accurate documentation of treatment time in minutes, to be

recorded on the MDS

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ADLs are government required, impact Quality Measures, affect Billing and Revenue, survey process, impact return to hospital rates

Two key elements:◦ How much assistance is being provided to the

residents◦ And, how many people need to assist the patient

during these activities

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This is for a PA county RMA-$265.88

RMB-$319.50

RMC-$339.25

RHA-$314.23

RHB-$353.75

RHC-$390.43

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CAH PPS

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Reasonable Cost

+Medical Necessity

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Patient name or MR#: Claim period/Dates of coverage: to

Eligibility requirements met: Three-day hospital stay/ 30-day transfer Patient in certified bed Patient eligible for Medicare and has benefits available Condition qualifying for Medicare treated in subsequent hospital stay or developed after admission to the SNF Medicare certification: Is certification/recertification completed, signed, and dated appropriately? Yes No, describe problems

Diagnoses/ICD-10-CM codes: (Check for accuracy of condition coded and diagnosis code; Diagnosis supported by physician documentation and on MDS) Principle diagnosis on UB-04: Code accurate? Yes No Diagnosis on MDS? Yes No Is this related to hospital stay and primary condition warranting Medicare coverage? Yes No Secondary diagnosis on UB-04: Coded accurately: Yes No Diagnosis on MDS? Yes No Do the diagnoses relate to Medicare coverage or services billed? Yes No Should other diagnoses be included? Yes No

H&PDischarge SummaryTherapy Tx Codes


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• One MAC recently reported that out of 508 errors identified in a CERT audit of certain Medicare claims, the contractor found that:– 311 errors were due to “insufficient documentation.”

• Notably, a majority of the errors in this category were because the medical record “did not contain a valid physician’s signature” or because a diagnostic test performed “did not contain a valid physician’s order” or an identification of the provider who rendered the service

– 132 errors were due to “lack of medical necessity” based on the medical documentation submitted

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87%

Pre-Pay audits are being conducted for claims with dates of service on or after April 1, 2017 that meet these criteria:◦ Claims for ultra-high rehabilitation RUGs◦ Original inpatient claims◦ 21X type of bill

Post-Pay audits of SNF claims on or after March 17, 2017:◦ The patient requires skilled nursing services or skilled rehabilitation services, i.e., services

that must be performed by or under the supervision of professional or technical personnel; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services

◦ The patient requires these skilled services on a daily basis◦ As a practical matter, considering economy and efficiency, the daily skilled services can be

provided only on an inpatient basis in a SNF◦ The services delivered are reasonable and necessary for the treatment of a patient’s illness

or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity”.

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CAH: too much therapy/ too long stay

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Technical Denial Reasons• Not responding to ADR timely• Physician Certification not complete• Therapy billing logs do not support billing• Illegible documentation• Hospital documentation not available

Denial Reasons:Lack of Functional Progress• Gaines not significant enough• No carryover of functional task• Lack of documentation• Outcome of therapy tx not documented• Failure o complete required treatment plan

Skilled Documentation NOT Supported• First progress note to support skilled therapy written 5 days after therapy began• Nursing notes do not show need for SKILLED nursing• Confusing or repetitive ADL documentation• “Resting Comfortably” documentation


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1. Back up for the time provided

2. Patient improved and can retain improvement

3. Rounded minutes instead or actual time

Facility NameTotal Stays

Distinct Beneficiaries Per Provider

Average Length of Stay (Days) Total SNF Charge

Amount Total SNF Medicare Allowed Amount

Total SNF Medicare Payment Amount

Total SNF Medicare Standard Payment Amount

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33

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634,313

120,796

114,432

138,782

2

22

20

10

318,510

66,590

66,590

79,567

3

22

22

8

201,557

52,700

48,408

59,238

4

44

42

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657,008

143,596

139,304

172,478

5

45

43

8

363,470

129,708

128,968

153,868

GA SNF PUF

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Section Three

One of the goals of this project is to have measurable outcome to present to referring hospitals and other health care partners – what have you been tracking/started tracking?1. ALOS (from your CFO) on a daily basis with a monthly avg2. ADC (from your CFO) on a daily basis with a monthly avg3. Rehab admissions versus Medically Complex4. Return to hospital within 30 days of discharge from your

swing bed (discharge to home health with follow up calls)

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Expectation of shorter stays with better outcomes

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RevenueStaffing productivity

AVERAGE DAILY CENSUS(Information can be provided from existing hospital reports)

ADC

Aug‐16 2.4

Sep‐16 1.7

Oct‐16 2.5

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

0

0.5

1

1.5

2

2.5

3

Aug‐16

Sep‐16

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

ADC

ADC

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AVERAGE DAILY CENSUS(Information can be provided from existing hospital reports)

ADC Budget

Aug‐16 3.8 5

Sep‐16 4.5 5

Oct‐16 4.3 5

Nov‐16 4.8 5

Dec‐16 5 5

Jan‐17 4.3 6

Feb‐17 4.8 6

Mar‐17 5.4 6

Apr‐17 5.5 6

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

0

1

2

3

4

5

6

7

Aug‐16

Sep‐16

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

ADC

Budget


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70/30 or 60/40

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Requires follow up calls to HH

CAH PPS

Data based on admissions by medically complex vs. therapy by RUG. You can combine all therapy RUGs into one column and medically complex into another column by month (January through March)

Also need to complete the data requested on the attached graphs and bring them

For one closed chart please bring the following (redacting specific patient information):

i. Physician Certification

ii. CMS 10123

iii. Detail bill

iv. UB-04

v. MDS for the claim

vi. 2 days of nursing documentation related to the claim

vii. 2 days of therapy documentation related to the claim

viii. ADL tracking sheet

Data based on admissions by medically complex

vs. therapy by RUG. You can combine all therapy

RUGs into one column and medically complex

into another column by month (January through

March)

Also need to complete the data requested on the

attached graphs and bring them

For one closed chart please bring the following

(redacting specific patient information):

i. Physician Certification

ii. CMS 10123

iii. Detail bill

iv. UB-04

v. MDS for the claim

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Physician Cert completed in TOTAL

Who is reviewing before billing?

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Who’s reviewing? Glucose “home kits”

reviewed When you look at the

list of medications is it accurate?

Personal care items are not billed to Medicare

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No Part B benefit in Swing Beds Switch to hospital provider number Type of bill = 12X Billable inpatient Part B services◦http://www.cms.gov/manual

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LOA◦ Occurrence Span Code 74◦ Non-covered days in FL 39-41 with value code 81◦ Revenue code 018X with no charges◦ Do N◦ OT include LOA days in 12X revenue code line

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Claims for patients no longer at a skilled level of care Two options◦ Patient dropped to non-skilled care within the month, needs denial

for other insurance◦ Patient previously dropped to non-skilled care

Qualifying Stay or Transfer Criteria Not Met◦ Use appropriate covered type of bill (181, 182, 183, 184) Note: Do not use bill types 180 (Swing Beds)

◦ •Bill all days and charges as covered – Covered/Coinsurance Days◦ •No occurrence span code 70◦ •Add remarks to claim stating no qualifying stay◦ •Medicare will deny for the appropriate reason

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PNEUMONIA /PULMONARY DISEASE TOTAL HIP OR TOTAL KNEE REPLACEMENT FRACTURED HIP

Lung assessment: note w heezes, level of pain and response to pain meds level of pain and response to pain meds

rales, crackles surgical site condition surgical site condition

Use of supplemental O2, O2 sats staples or sutures staples or sutures

Use of accessory muscles any hip precautions any hip precautions

c/o chest pain use of CPM if ordered Weight bearing status and ability to maintain it

medications and responses to Weight bearing status and ability to maintain it Resident/caregiver education and response

same Resident/caregiver education and response Use of anticoagulants-any adverse reaction

endurance level Use of anticoagulants-any adverse reaction Progress to discharge plan

ability to participate w ith rehab Lab results f/u w ith ortho

lab results Progress to discharge plan participation w ith skilled therapy

vital signs f/u w ith ortho vital signs

participation w ith skilled therapy safety issues

vital signs new orders

new orders

ANTICOAGULATION THERAPY UTI CVA

Medication used Any burning w ith urination Level of consciousness

Signs or symptoms of bleeding Frequency or urgency Neuro vital signs

bruising, hematuria, + guaiac stools Change in continence Sw allow ing issues

Pain Pain Communication issues

Pallor or cyanosis Lab results Ability to perform ADL’s and amount of assist

Lab results Antibiotic ordered and any adverse effects needed

Resident/caregiver education and Vital signs Skin integrity esp on affect side

response to same New orders Safety concerns

Safety concerns Resident/caregiver education Anticoagulants if used

New orders Participation w ith skilled therapy

Progress to discharge

Resident/caregiver education

New orders

s/s depression

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1. Discuss coverage of services allowed in a swing bed

2. Understand the level of care plays in Medicare determination of coverage and payment for services

3. Talk with your referring hospitals and physicians

4. Track and show providers, ACOs, etc. good outcomes

5. Educate and Train and Teach and Learn

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1.

2.

3.

4.

5.

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1. Recognize the basic audit targets, coding risks and how to set up double checks

2. Identify opportunities for census growth, revenue enhancement, and staff productivity

3. Focus on tracking key monitors and using information for revenue growth and protection

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http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SwingBedFactsheet.pdf


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Medicare Benefit Policy Manual, CMS IOM Publication 100-02, Chapters 1,6,8 and 10

Medicare Claims Processing Manual, CMS Publication 100-04, Chapters 1,3,4 and 15

CMS MLN Publications http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf

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Internet Only Manuals (IOM)◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

Publication 100-02, Chapter 8 – Coverage of Extended Care Services

Publication 100-04, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS)

Publication 100-04, Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing

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Contact InformationDesi Barrett, Webinar Program Manager

[email protected]

Kristy Thomson, COO

[email protected]

Jennie Price, Director of Business Development

[email protected]

Kerry Dunning, RSBM Program Trainer

[email protected]

focus on financials final presentation...section 4432 of the balanced budget act of 1997 (bba, pub....

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