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Updates from the May 12 SNF ODF

During the May 12 SNF Open Door Forum (ODF), CMS provided callers with information about what was included in the SNF PPS proposed rule, some MDS 3.0 updates, and touched on a few other topics. Let’s take a closer look at some of the highlights.

Sheila Lambowitz, director of CMS’ Division of Institutional Post-Acute Care, began the call with a discussion of the SNF PPS proposed rule, which was put on display April 29 and published in the May 6 Federal Register. She explained that CMS did not propose a rate setting methodology in the proposed rule for fiscal year (FY) 2012. Instead, CMS included lengthy discussions about the two options they are considering. They did this because the past year was not a typical year and changes in the payment system need to be made. In a typical year, the rate setting methodology is pretty straightforward. This is not a typical year because we’ve had major changes recently, such as the recalibration of rates in FY 2010 due to changes that occurred because of refinements made in 2006 that created an excess in budget neutrality, as well as the implementation of MDS 3.0 and RUG-IV.

“When we introduce new classification system, we try to do in a budget neutral manner. We want to make sure there are no steep drops or increases in payment simply because we changed the payment system,” Lambowitz said. “This year, we were not terribly successful in doing that. There were sharp spikes in payments made to nursing homes under RUG-IV that exceeded budget neutrality by a very significant amount.”

CMS originally projected that the payment days in the ultra high rehab category would go down when we switched from RUG-III to RUG-IV due to the changes made to concurrent therapy and the inability to count things that occurred prior to admission.

However, this did not happen.

“Instead, we found the same 43%, approximately, was being calculated in ultra high rehab categories under RUG-IV, because providers changed method they used to provide therapy,” Lambowitz said. “In the past, we saw an approximate 25% and 75% split between individual and concurrent. Now we are seeing almost no concurrent therapy, nearly 90% individual, and the rest in group.”

So CMS needs to recalibrate the system in FY 2012 so the payments would meet the budget neutrality model. This is where the two new models come from.

Lambowitz also said CMS realizes that it should have treated group therapy the same way they treated concurrent therapy as far as counting the therapist’s reimbursable time.

“If we won’t let a therapist count two hours of treatment time for treating two residents for one hour, then we shouldn’t count allow a therapist to count four hours when they treats four residents for an hour in group,” Lambowitz said. “So we are proposing that group therapy become a 4:1 allocation methodology.”

Lambowitz also discussed issues CMS found with observation periods and changes in care after assessments are completed. One of these issues was that the level of therapy a resident receives can change shortly after the observation period for the assessment ends, yet the facility would get paid at the rehab rate generated by that assessment for the remainder of the payment period. To fix this issue, CMS is proposing that facilities must revisit a resident’s records within seven days of the last ARD to determine if that resident is still receiving the same level of therapy as calculated during the observation period. If they are not receiving the same amount, the nursing facility will have to complete a Change of Therapy OMRA to change payment category to reflect the services actually provided. Lambowitz also made sure to call people’s attention to the fact that this could also increase the reimbursement rate if the resident is receiving more therapy.

Lambowitz also discussed the proposed changes to the End of Therapy OMRA, which we discussed in detail in an earlier blog post about the SNF PPS proposed rule.

The next CMS official to make announcements during the ODF was Tom Dudley, MS, RN, of CMS’ Division of Chronic and Post Acute Care, Office of Clinical Standards and Quality. According to Dudley, CMS is in the process of completing initial evaluation of MDS 3.0 data and has identified a situation where there are a large number of dashes.

“Up to 40% of assessments have dashes, even in Quality Measure items, such as pain,” Dudley said. “CMS will be providing more detailed guidance on when dashes are appropriate in the near future.”

Dudley also announced that an update to the RAI User’s Manual will be coming out late this month or early June. He explained that the changes made to the manual are more so clarifications to certain sections than updates or completely new guidance.

CMS officials rounded out the call with information on the QTSO website and a new background check program for long-term care employees before opening the lines for Q&A.

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