SNFs Under Scrutiny

SNFs Under Scrutiny

Some of you may have noticed that I am not always very nice to some insurance companies. And deservedly so. But I also point out the failings of the provider community when they come to light. And a recent study from researchers in Texas and New York took a close look at skilled nursing facility (SNF) billing. They titled their article “Overbilling and Killing? An Examination of the Skilled Nursing Industry.”

First, though, I want to make reference to data published two years ago looking at the day of discharge from SNFs for Medicare patients.

Most of you know that Medicare Part A pays for the first 20 days in a SNF at 100 percent. As you can see, the probability of discharge on day 20, especially for those patients without a supplement, was significantly higher than other days. Is this coincidence? It’s hard to imagine.

Now, this recent study, just published in October, looked at SNF billing patterns before and after the implementation of the Patient-Driven Payment Model (PDPM) in 2019. Prior to this, SNFs were paid based on the amount of therapy provided to patients, but PDPM looks at nursing needs, therapy needs, and non-therapy ancillary services, which are all based on the patient’s diagnoses.

And the reporting of those diagnoses that raised the payment rates increased markedly as PDPM started.

The authors note that the data shows that systems with higher levels of excess rehab during the pre-PDPM era subsequently experience more intense billing under the PDPM era. Not a good look for the SNFs, is it?

In another SNF topic, I suspect all of you have had a patient refused at a SNF because of excess medication costs. Now, in this case, the SNFs have a reasonably valid reason for their actions. The consolidated billing system the Centers for Medicare & Medicaid Services (CMS) has in place for Part A SNF stays does not account for the ever-increasing costs of many drugs.

Well, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a study last month looking at this issue from a unique viewpoint; they looked for Medicare Part D expenditures for medications when the patient was in a Part A SNF stay. In other words, that suggested that the patient’s medication, instead of being provided by the SNF, was being filled at a pharmacy and then brought to the SNF for the patient to take, or the pharmacy that supplies medications to the SNF was billing the patient’s Part D plan, rather than the SNF.

The most important part of this report, which I hope opens some eyes at CMS, is a case they describe. Let me quote it directly: “a SNF accepted admission of a Part D enrollee from a hospital only when the family assured the SNF that it would provide to the facility the drug the enrollee was taking. The SNF obtained from the family a drug used for the treatment of lung cancer and administered 27 tablets, which cost $15,494.

According to the SNF, the cost of this drug was more than Medicare paid the SNF for the entire stay, and this was the only way they could provide the needed care to the patient to allow them to successfully return home.”

Let’s hope CMS realizes it is time to reform the consolidated billing system.

Finally, the 2025 Inpatient-Only list is out, and there are three additions and one removal. You can find the list and changes on my web page: ronaldhirsch.com.

EDITOR’S NOTE:

The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.

Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.

November 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Outpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

September 5, 2024
Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.

September 12, 2024

Trending News

Featured Webcasts

Patient Notifications and Rights: What You Need to Know

Patient Notifications and Rights: What You Need to Know

Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.

December 5, 2024
Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks.  Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.

November 19, 2024
Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

October 24, 2024
The OIG Update: Targets and Tools to Stay in Compliance

The OIG Update: Targets and Tools to Stay in Compliance

During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.

September 19, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24