One and a half years after implementing the Patient-Driven Payment Model (PDPM), how is your professional care organization performing in terms of operations and finances?
Chances are, you may not know it yet. In more than two decades, the first major change in post-acute care reimbursement occurred a few months ago, when it – and everything else – was overturned by the Covid-19 pandemic. Before most of us have time to adjust, we put PDPM into practice while responding to public health emergencies. Talk about how to build an airplane while flying.
Fortunately, the federal government realized that without its help, the long-term care industry could be destroyed by the pandemic. Rescue funds flowed quickly to the facility; regulators agreed to abandon long-term underwriting requirements that could prevent patients from getting the skills needed to care. Importantly, the Center for Medicare and Medicaid Services (CMS) also appears to have postponed facility reviews and audits related to the implementation of PDPM.
However, this grace period may soon be over. CMS recently revealed that, compared with previous payment models, PDPM, which aims to remain revenue-neutral, increased its reimbursement for SNF by more than $1.7 billion last year, raising concerns about the upcoming review of potential payments. Although you may not see additional document requests (ADRs) or denials from federal regulatory agencies related to PDPM right now, you may receive them from managed care companies. As regulators continue to be chased after the suspension of review activities in 2020, they will certainly not be too far behind.
As review activities increase, what can your factory do to maintain compliance and avoid any audits?
- Accurately evaluate, then record, record, record
Recent PDPM-related denials from managed care companies usually have one thing in common-the lack of adequate documentation about the patient’s condition.
Under the previous payment model, reimbursement was linked to the amount of care provided. But under PDPM, payment is related to the needs of individual patients-the more complicated the patient’s condition, the more compensation the SNF will receive for providing care to the patient.
This is why your clinicians and staff accurately assess the condition of each patient and ensure that it is fully documented. This should include an assessment of the conditions that caused the patient to enter your facility and any other medical issues that may affect the patient’s ability to improve under your care. Don’t underestimate the impact of seemingly unrelated problems (such as vision and hearing impairments or dental problems) on the patient’s ability to show improvement. All conditions must be identified and recorded to accurately describe the patient’s condition.
All bedside staff need to be regularly trained and retrained on proper recording methods. The record should explain why your patient is eligible for SNF hospitalization, what kind of care the patient needs, and the expected results of the recommended treatment interventions.
In addition, your factory should establish an appropriate system to make accurate and complete documentation as simple as possible. For example, it is common to be rejected due to lack of documentation related to the patient’s functional capabilities. This information is collected during the first three days of the patient’s hospitalization. However, this can be complicated when patients are admitted after the normal “working hours” of key personnel, such as evenings and weekends. Whenever a patient arrives at your facility, you need to develop a process to ensure that critical functional information is continuously evaluated and recorded.
- Take the Goldilocks approach
Since reimbursement under PDPM is no longer tied to the amount of care the patient receives, your clinician should focus on determining which care is “just right” based on each patient’s improvement potential. If the additional care you provide is unlikely to improve the prognosis of complex patients, you may be subject to scrutiny. However, if your patient’s characteristics indicate a high likelihood of improvement, but he or she does not receive the necessary care that may promote improved results, then the same can be said. Simply reducing the amount of care provided by your institution will not put you under the sight of regulatory agencies.
Most importantly, if you do receive an audit or facility review notice, do not assume that this means that you have committed fraud or that the patient care services you provided will not be reimbursed. If you have created a compliance culture among your employees and developed a process to address any identified weaknesses, then you should stand on the other side and become a stronger and more compliant organization.
Image: Hollygraphic, Getty Images
