Tracking and Analyzing Therapy Utilization for Claim and Denial Risk Minimization

1. Tracking and Analyzing Therapy Utilization to Minimize Claim and Denial Risk Reginald M. Hislop III, PhD Managing Partner H2 Healthcare, LLC Galena, IL

2. Learning Objectives • At the completion of this educational activity, the learner will be able to: • Identify how the Patient-Driven Payment Model (PDPM) will impact SNF Medicare reimbursement, with a focus on how rehabilitation therapies are provided • Describe how to efficiently map therapy delivery to ensure maximum available reimbursement • Understand strategies to manage the therapy and care delivery transition under the PDPM, with emphasis on the model’s changes regarding group and concurrent treatment • Identify internal operational changes needed now to build organizational competence under the PDPM to ensure Medicare billing integrity and compliance is maintained

3. PDPM: SNFs • Replaces current RUG-IV model for fee-for-service Medicare beneficiaries (not applicable for Medicare Advantage plans and their beneficiaries) • Began October 1, 2019, with NO phase-in period • Is meant to be budget neutral for CMS and SNFs • Impacts payment mechanics under Part A Medicare ONLY. Does not change any Conditions of Participation (regulations), VBP, QRP, or benefit qualification requirements (e.g., three-day prior hospital inpatient stay for SNF coverage)

4. PDPM Mechanics: An Overview • Payment is based on case mix and patient care needs, determined by the admission MDS • Payment is derived from six case-mix categories: • PT • OT • SLP • Nursing • Non-therapy ancillary services (e.g., IV, enteral feedings, wound treatments such as a wound vac) • Non-case mix (room and board–related costs such as utilities, capital, etc. that are constant for any patient condition – non case-mix adjusted)

5. PDPM Mechanics: An Overview (cont.) • Payment is variable, based on length of stay • Non-therapy ancillary services payments decline on day 4 (2/3rd reduction) • On day 21, PT/OT rates reduce by 2% and continue to decline by 2% every 7 days • Payment amount is determined by the base rates that correspond to each payment category (six categories) and the case-mix values within each category – the two multiplied together (excluding the non-case mix category, which is flat) • Classification into a clinical category is based on the primary ICD-10 diagnosis reason for the SNF stay (may be different than the hospital admitting primary diagnosis)

6. PDPM and PT & OT Payment Mechanics • Clinical reason for SNF stay places patient in one of 10 clinical PDPM categories: 1. Major Joint Replacement or Spinal Surgery 2. Cancer 3. Non-Surgical Orthopedic/Musculoskeletal 4. Pulmonary 5. Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) 6. Cardiovascular and Coagulations 7. Acute Infections 8. Acute Neurologic 9. Medical Management 10. Non-Orthopedic Surgery • The above map to a PDPM PT and OT clinical category (see slide 7). • Applying the patient’s functional status on admission (section GG from the MDS assessment) falls into one of 16 case-mix classification groups (see slide 8). • Payment is derived from the category plus the case-mix classification. The case-mix weight is multiplied by the rate applicable for the clinical category.

7. Category Mapping PDPM Clinical Category • Major Joint Replacement or Spinal Surgery • Non-Orthopedic • Acute Neurologic • Non-Surgical Orthopedic/Musculoskeletal • Orthopedic Surgery (Except Joint Replacement/Spinal) • Medical Management • Acute Infections • Cancer • Pulmonary • Cardiovascular and Coagulations Collapsed PT & OT Clinical Category • Major Joint Replacement or Spinal Surgery • Non-Orthopedic Surgery/Acute Neurologic • Other Orthopedic • Medical Management

8. PT and OT Case-Mix Classification Groups Case-Mix • Clinical CategorySection GG Score PT OT Case-Mix Group PT Index OT Index • Major Joint Replacement or Spinal Surgery 0–5 TA 1.53 1.49 • Major Joint Replacement or Spinal Surgery 6–9 TB 1.69 1.63 • Major Joint Replacement or Spinal Surgery 10–23 TC 1.88 1.68 • Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53 • Other Orthopedic 0–5 TE 1.42 1.41 • Other Orthopedic 6–9 TF 1.61 1.59 • Other Orthopedic 10–23 TG 1.67 1.64 • Other Orthopedic 24 TH 1.16 1.15 • Medical Management 0–5 TI 1.13 1.17 • Medical Management 6–9 TJ 1.42 1.44 • Medical Management 10–23 TK 1.52 1.54 • Medical Management 24 TL 1.09 1.11 • Non-Orthopedic Surgery/Acute Neurologic 0–5 TM 1.27 1.30 • Non-Orthopedic Surgery/Acute Neurologic 6–9 TN 1.48 1.49 • Non-Orthopedic Surgery/Acute Neurologic 10–23 TO 1.55 1.55 • Non-Orthopedic Surgery/Acute Neurologic 24 TP 1.08 1.09

9. PDPM and Speech • Uses the PDPM clinical category (10), patient’s cognitive function, the presence of a speech comorbidity, and whether the patient has a swallowing disorder or needs and altered diet – determines case mix and payment • Speech comorbidities are (present on admission): Aphasia Laryngeal cancer CVA, TIA, or stroke Apraxia Hemiplegia or hemiparesis Dysphagia Traumatic brain injury ALS Tracheostomy care Oral cancers Ventilator or respirator Speech and language deficits • Swallowing disorder/dietary needs are captured on the MDS

10. Speech Case-Mix Classification Groups Presence of Acute Neurologic Condition SLP-Related Comorbidity, or Cognitive Mechanically Altered Diet Impairment Swallowing Disorder SLP Case-Mix Group SLP Case-Mix Index None Neither SA 0.68 None Either SB 1.82 None Both SC 2.66 Any one Neither SD 1.46 Any one Either SE 2.33 Any one Both SF 2.97 Any two Neither SG 2.04 Any two Either SH 2.85 Any two Both SI 3.51 Any three Neither SJ 2.98 Any three Either SK 3.69 Any three Both SL 4.19

11. PDPM Nursing and Non-Therapy Ancillary • Nursing follows same basic format as RUG-IVs for group assignment. Case-mix component is driven by extensive services, certain clinical conditions, depression, restorative nursing, and functional score to define a case-mix group. More detail is available here: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_Template_Payment_Overview_Final.pdf • NTA payments use a non-therapy ancillary comorbidity score to assign the patient to a group. Based on the score, an NTA case-mix weight is derived. Other than the presence of HIV/AIDS, all comorbidity scores are derived from the MDS. Examples of comorbidities include parenteral feeding, IV meds post-admit, ventilator/respirator post-admit, infections, etc. Each comorbidity has a point value – more points, higher case-mix weight.

12. Key Differences With PDPM • Only three (possible) MDS assessments: one on admit, one on discharge, and one if the patient has a significant change of condition. • With change to case mix–driven payment model, therapy minutes become irrelevant for payment. Facilities will still track and report minutes, but this is a QA function for CMS to ensure that the same level of therapy is being provided under PDPM as under RUGs. • Under PDPM, up to 25% of the therapy provided in a facility MAY BE group or concurrent. Caution: Ensure that the provision of group or concurrent is clinically warranted (see next slide for applicable definitions). • The change of condition MDS can modify payment, but only at the point in time the conditional change occurred. • Payment is variable by length of stay.

13. Concurrent vs. Group Therapy • Concurrent: Is defined as the treatment of two residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line of sight of the treating therapist or assistant for Medicare Part A. When a Part A resident receives therapy that meets this definition, it is defined as concurrent therapy for the Part A resident regardless of the payer source for the second resident. • Group: Is defined for Part A as the treatment of four residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals.

14. Key Differences With PDPM: MDS and Section GG • MDS is used for payment classification groups—varies by case-mix groups • Admission MDS and diagnoses = 100% of payment weight and level! • Section GG determines PT/OT case-mix • Higher points means higher independence • Opposite G • Alignment with QRP • Not applicable, refused, not attempted are coded as dependent • Includes 10 items; average scores for multiple item areas: bed mobility (2), walking (2), transfer (3), eating (1), toileting (1), oral hygiene (1)

15. Major Joint Replacement or Spinal Surgery/Urban

16. Rate Schedule for Example

18. Polling Question #1 Does your facility or organization use a contract therapy company to provide rehabilitation services? _____Yes _____No

19. PDPM and Therapy • Even though minutes, etc. are no longer relevant to the provision and payment for therapy, CMS has assumed that MOST therapy will continue to be provided one-on-one. SNFs with contract providers need to take great care to ensure that the contractor does not automatically ramp up inpatient therapy on a group and concurrent basis to the 25% threshold! • Unless the facility has experienced a significant change in overall case-mix from when under RUGs to PDPM (fewer therapy-qualified residents), there would be no logical clinical reason to change treatment practices. • All group and concurrent treatment minutes will be reported on the MDS (discharge).

20. Five Therapy and Reimbursement Implications Under PDPM • Reimbursement is no longer tied directly to the provision of therapy! The overall clinical picture of the resident is the driver. • Productivity for therapists is no longer a function of billable treatment time in therapy. • More therapy does not equal MORE revenue or reimbursement! PT and OT are split from speech, and each is driven clinically by diagnosis, functional status, etc.—not minutes! • Length of stay impacts payment adversely. The methodology of PDPM is to provide care efficiently and not maximize length of stay! • MDS job is much more clinically focused—it’s not just about putting patients in high rehab categories. Total patient care must be assessed and captured.

21. Revenue Integrity and Compliance Risk Management Under PDPM Therapy Implications

22. Group and Concurrent Therapy Risk • The issue: Substantial jump/increase in therapy minutes via group and concurrent. • Why: Contractors fearing reduced revenues via PDPM will look to save labor costs via providing more group/concurrent therapy. • The risk: CMS will audit significant changes in therapy provision via discharge MDS and minutes of therapy provided. If a facility transitions rapidly from predominantly one on one to a sizable percentage of group/concurrent treatments, a “red flag” is raised. • Point: If facility has predominantly billed Ultra-High and Very High Therapy RUGs, this therapy is one to one driven. Unless a significant change in case-mix occurred on 10/1, no reason for therapy provided to patients to change.

23. Treatment Plans and Minutes Recorded Risk • The issue: MDS assessments of care required should not substantially change, even though payment is changing. Treatment plans should not change either based on common/like patients and needs, pre-10/1 vs. post-10/1. • Why: PDPM is payment driven but the implementation does not change the type of patients and patient needs facilities will experience. • The risk: If minutes of therapy as reported change substantially, CMS will audit treatment/care plans to see if under-assessing or manipulation of assessments for care plan development has changed (e.g., a hip fracture pre 10/1 should be treated the same post 10/1). • Point: Accurate assessment and care planning is required, more so now than ever before—for payment and compliance purposes.

24. Length of Stay Risk • The issue: RUGs incented greater lengths of stay, whereas PDPM with variable payments declining after day 20 (PT, OT, ST) incents proper LOS management. • Why: Shorter lengths of stay (suddenly) will likely trigger CMS review plus unhappy patients, improper discharge planning, increased VBP risks. • The risk: CMS is watching therapy utilization in terms of care provided NOW vs. BEFORE … length of stay is a measured, risk variable. • Point: Facilities that haven’t been aggressive in LOS management pre-PDPM should not quickly jump to shortening lengths of stay. CMS will compare facility utilization and start inquiries.

25. Outcome Risk • The issue: Changes in operations to accommodate payment changes often equate to changes (negative) in patient outcomes and experience • Why: Facilities haven’t planned accordingly and begin to see reimbursement changes, and then attempt to control revenue reductions via expense reductions • The risk: Increased complaints, survey risk, reputation risk, rating (star) risk • Point: Facilities should know by now, how their Medicare reimbursement will change under PDPM and thus, created plans for any changes that DO NOT IMPACT resident care outcomes

26. Managing the Risk: Therapy Staffing • PDPM begs for a different therapy staffing model. Contracts should be viewed as an extension of the facility care delivery team and tied to shared-risk models and case-mix payment systems. PER MINUTE CONTRACTS ARE USELESS FOR PDPM! • Facilities must now more than ever manage the therapy provided to their residents—regardless of who provides it. How? • Therapy and treatment logs • MDS review against therapy documentation • Treatment time and by whom • Length of stay • Care satisfaction and outcomes (hospitalization rates, etc.)

27. Managing the Risk: Watch Your Performance • What is PEPPER? • PEPPER is sponsored by the Centers for Medicare & Medicaid Services (CMS) and is an educational tool available to help providers proactively monitor their claims data and work to prevent improper Medicare payments. PEPPER summarizes one provider’s Medicare claims data statistics in areas that have been identified as at risk for improper Medicare payments. It identifies when their statistics are different from most providers in the nation, which may represent an increased risk for improper payments. PEPPER can support an agency's government compliance efforts by helping them identify where they are an “outlier” so they can self-monitor billing practices and focus auditing and monitoring efforts.

28. Sample PEPPER Graph

29. Polling Question #2 Have you reviewed your PEPPER report for your SNF? ______ Yes ______ No If no, why not?

30. Managing the Risk: CASPER • CASPER covers resident quality measures—short-stay and long-stay. • Short stays correlate to post-acute/Medicare: • Moderate to severe pain • New/worsened pressure ulcers • Antipsychotic use • Medicare and quality: Poor performance on CASPER leads to claim audits. Medicare does not pay for noncompliant care or sub-standard care. • Impacts survey engagement and star ratings.

31. Managing the Risk: CMS Five-Star Quality Rating System • Ratings published for: • Survey/inspection • Staffing overall • RN staffing • Quality measures • Short-stay • Long-stay • Five stars = highest rating. Only 65 facilities in the nation (over 15,000 total) have five stars in each rating category. • RACs monitor these reports and CASPER reports for claim integrity purposes.

32. Managing the Risk: Quality • Quality that is unequal to billing levels or survey/certification results = claim risk • Changes in quality = claim risk • Changes in complaints = claim risk • Changes in utilization, days, minutes provided = claim risk • MAP changes (RUGs vs. PDPM) = claim risk • Disgruntled staff = claim risk (#1 fraud claim starter is a whistleblower!)

33. Minimize the Risks: Tips and Strategies • Review and redo therapy contracts to match how PDPM works. • Watch how therapy is provided to your residents—therapy logs, treatment minutes, length of stay, group and concurrent utilization, etc. • AUDIT the MDS—does it match your documentation in therapy and in nursing? • AUDIT your quality and the reports—PEPPER, CASPER, Five-Star • Use benchmarking applications—OnlyBoth.com or Benchmine.com! • Sample audit your claims—pull a few each quarter and compare what was billed with the care that was documented, assessed, and provided. Correct any gaps or holes.

34. Final Touches: My Top Five • Educate staff—the more they know, the more they grow! • QAPI—use it! Have an effective program that looks at care and billing/claims. • Watch the stuff that matters—how and how much therapy is provided, discharge and rehospitalization outcomes (VBP matters), QRP submission data, Medicare cost per beneficiary stay. • Patient/resident experience/satisfaction—critical to making sure holistic outcomes are achieved. • Use outside resources—facilities can’t audit themselves. Avail yourself of expert resources and tools!

35. Thank you. Questions?rhislop@h2healthllc.comFor additional resources, articles, tips, etc., go to rhislop3.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.