Providers ‘on notice’ as CMS pressures states to shift Medicaid pay metrics

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[MM Curator Summary]: CMS is working to re-configure how LTC providers get paid, but many providers are not set up to code correctly under the proposed models.


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Providers still struggling to accurately capture diagnoses that drive federal reimbursement will be doubly left behind as more states start to use Patient Driven Payment Model-like systems to determine long-stay Medicaid pay rates.

That was the warning Wednesday from reimbursement experts Vincent Fedele, chief operating officer of CORE Analytics, and Michael Sciacca, chief operating officer at Zimmet Healthcare Services Group.

This is what most Medicaid systems will be based on, very similar drivers or essentially the same drivers,” Sciacca said in a webinar hosted by Simple LTC. “Really, the emphasis [will be] on the depression end split and the Section GG scoring, and the identification and documentation of those drivers is not going to vary much when it comes to a system that focuses on the long-term care population.”

Struggles in capturing documentation in the Minimum Data Set have persisted since the concept of PDPM was introduced in 2018. Yet many providers continue to miss opportunities to appropriately bill for higher-paying conditions such as neurological diagnoses, speech language pathology needs and ancillary services.

“We have been seeing providers who have been getting better with capturing these items, really hunting in the medical record to find the acuities documented within the look-back period and then capturing those on the associated MDS,” said Fedele, who is also a partner at Zimmet. 

But persistent patterns continue to separate the top and bottom performers in Core Analytics data, which represents more than 3,000 skilled nursing facilities nationwide.

Among those are the ability to code patients in the Special Care High nursing category, which can be driven by the use of IV fluids or coding of COPD-related shortness of breath when lying down. Nearly 59% of the Top 10% of Core’s clients code for those conditions, while just 18% do so among the bottom 10%. That without any real expected differences in patient acuity or needs, Fedele said.

The top 10% of performers also are much more likely to code for one or more speech therapy items in SLP Profile 1, with about 37% documenting all three eligible items. About one-third of the bottom 10% record no needs in the same SLP Profile.

Fedele and Sciacca also noted major differences among the top and bottom providers when it comes to capturing depression for a special care low payment adjustment. Among the top 10%, 49% are being reimbursed; just 4.4% of the bottom 10% collect those payments.

Little things add up in new system

Even missing minor, chronic issues can mean major money lost over time, noted Sciacca, calling out skin issues, malnutrition and chronic respiratory items as widely missed opportunities in the non-therapy ancillary category.

And those kinds of diagnoses could be common among long-stay patients, whose payments may soon need to be based on similar models.

CMS announced in September that it would be eliminating Section G and other elements of the MDS, effective next October. Section G, used to capture functional status of residents, has been a key component of state reimbursement-setting.

Now, many states will likely be forced to abandon their metrics, which often still mimic PDPM’s predecessor, the RUGs system.

Sciacca noted there are currently more than 30 different state systems for assigning Medicaid payment, and only Wisconsin and Illinois have so far moved to a system that mirrors some of PDPM’s elements. But, by nature, assessments of long-stay Medicaid patients will in many ways differ from the Medicare model that pays more highly for post-acute recovery and needs.

“Notice has been given,” he said. “This is CMS’ way of forcing the issue.”

In either case, providers need to prepare for changes and do a better job of understanding how well they’re collecting, versus their peers. Seeing weaknesses could not only help bring in more Medicare dollars for care provided but shore up processes that improve documentation and communication about diagnoses before state changes take effect.

Currently, according to Core data, about 55% of Medicaid revenues are derived from rehab, which the PDPM system de-emphasizes as a payment driver. The question becomes, Sciacca said, whether states will be able to come up with systems with appropriate reimbursement sensitivities.

“The long-stay PDPM and short-stay PDPM residents are not the same thing,” Fedele said. “Start to think about what programs and systems you need to implement in the event your state does convert to that PDPM for Medicaid.”