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Post Acute Care: Nursing Facilities,

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Presentation on theme: "Post Acute Care: Nursing Facilities,"— Presentation transcript:

1 Post Acute Care: Nursing Facilities,
Reimbursement Primer for Compliance, Ethics and Legal Officers: “Everything You Have Always Wanted to Know About Reimbursement but Were Afraid to Ask.” Post Acute Care: Nursing Facilities, Skilled Nursing Facilities, Assisted Living April 17, 2007 Janine Boudreau, Janine Boudreau Healthcare Consulting, Inc. Lynda Hilliard, Senior Manager, Life Sciences & Healthcare Regulatory Services,Deloitte & Touche LLP W. Scott Plumb, Senior Vice President, Massachusetts Extended Care Federation Moderated by Lawrence W. Vernaglia, Foley & Lardner, LLP

2 Session Objectives Gain insight into the market for the primary care sectors for Post Acute Care Obtain a general understanding of the primary reimbursement streams for skilled nursing facilities (“SNF”), assisted living faciities (“ALF”), and nursing homes (“NH”). Gain insight into government reimbursement compliance issues in this marketplace

3 Post Acute Care Discussion will be segmented into 3 areas:
Industry Overview – Scott Plumb High Level Revenue Cycle Overview – Janine Reimbursement Compliance Issues – Lynda Hilliard Questions and Answers from Participants

4 Industry Overview

5 Provider Payer Mix Comparison Nursing homes are uniquely dependent upon Medicaid to provide quality health care Nursing Home Payer Mix Home Health Payer Mix Acute Hospitals Payer Mix

6 The Nursing Facility “Dollar”: Breakdown of Nursing Home Spending Salaries and benefits represent 71 cents of every dollar spent by nursing facilities Administration (Administrator, Accounting, Clerical) Physical Plant (Mortgage and Property Taxes) General Expenses/Operating (Supplies, Food, Utilities & Liability Insurance) All Staff Wages & Benefits Based on Division of Health Care Finance and Policy nursing facility cost reports

7 Source: DHCFP Nursing Facility Annual Cost Reports
50,000 Nursing Facility Employees The nursing facility provider community is a major economic engine and is the largest employer in some communities Social/Medical 32,000 Source: DHCFP Nursing Facility Annual Cost Reports

8 Sources: MECF Annual Wage Surveys 1999-2006
Nursing Facility Direct Care Nursing Staff Median Wage Increases:1999–2006 Nursing facilities are good employers Average annual increase of 4.2% 3.0% 3.1% 3.0% 3.8% 4.1% 7.9% 4.6% Sources: MECF Annual Wage Surveys

9 3,700 Nursing Facility Direct Care Staff Vacancies Despite Investment in Staff Wages & Benefits, Significant Vacancies Exist Certified Nurse Aide 1,800 Sources: DHCFP Annual Nursing Facility Cost Reports and MECF Annual Wage Surveys

10 Average Daily Minutes of Nursing Care Reimbursed By Medicaid*1
Source: MassHealth and Division of Health Care Finance and Policy; Prepared by: Massachusetts Extended Care Federation *1The average daily minutes of nursing care reimbursed by Medicaid (197 minutes in 2007) falls short of the average daily minutes of care provided by nursing homes (204 minutes in 2007).

11 Medicaid Nursing Facility Resident Acuity – 2006 Nearly all nursing home residents require extensive nursing care % of Total Medicaid Residents in Case Mix Category MMQ Category H J,K L,M N,P R,S T Minutes (Range)  – – – – Minutes (Median) Source: MassHealth Unaudited Management Nursing Minutes Score

12 Nursing Facility MEDICAID UNCOMPENSATED CARE Per Day, $500,000 annual Medicaid loss per Medicaid participating nursing facility Sources: BDO Seidman Reports; MECF Estimates *User Fee Program Implemented (2003); User Fee Program Maintained In Subsequent Years

13 Consumer Satisfaction in Massachusetts Nursing Homes Independent state survey shows nursing facility consumers are highly satisfied % of nursing homes Consumers who are: Source: Massachusetts DPH Nursing Home Satisfaction Survey Results, December 2005

14 Nursing Facility Spending As a Percentage of Total Medicaid Spending: FY1999-FY2006
Sources: SFY Actual (MassHealth Budget Office); SFY 2005-FY2006 Massachusetts Taxpayers Foundation (April 2005 Report, p.14) and MECF Nursing Home Data

15 Continuum of Long Term Care
At Home: Routine Care At Home: Informal Support At Home: Formal Support Assisted Living Facility- Based Care Short Term Care Hip Fractures Knee Replacements Stroke Cardiac Disease Long Term Care Alzheimer’s Disease Advanced Dementia Multiple Illnesses Congestive Heart Failure Advanced Diabetes Neurological (MS, Severe Brain Injury) Hospice

16 High Level Revenue Cycle

17 Pre-Admission Checklist
Review and Log Referral Verify Benefits Co-Insurance Medicaid – Eligibility Date/Type Managed Care – Policy Hospice – Provider Other – Review with Administrator Price Out P.O. Medications Call for IV Medication Pricing Review Clinical Information with DON or designee Review Whole Referral with Administrator/COO Offer Bed Immediately for Approvals Contact Chief Clinical Officer for Denials Admissions Stand Up Meeting Assign Guardian Angel Sign Resident In

18 Payor Mix Medicare HMO/Managed Care Private Medicaid

19 Special Populations Palliative Hospice HIV

20 Billing Cycle Pre-billing for: Private Patient Paid Amount (PPA)
HMO/Managed Care Prior Authorization Medicare/Medicaid Verifying level prior to actual billing

21 Rebilling and Reconciliation
Credit Balances Adjustments Denied or Suspended Claims

22 Reimbursement Compliance Issues

23 SNFs - Focus of 2007 OIG Work Plan
Billing/Reimbursement Skilled Nursing Facilities’ Involvement in Consecutive Inpatient Stays Skilled Nursing Facility Payments for Day of Discharge Skilled Nursing Facility Consolidated Billing Submission of Skilled Nursing Facility No-Pay Bills HMB (Hospice) Payments to Nursing Home

24 SNFs - Focus of 2007 OIG Work Plan
Covered Services Skilled Facility Rehabilitation and Infusion Therapy Imaging and Laboratory Services in Nursing Homes Implementation of Medicare Part D in Nursing Facilities Inappropriate Psychotherapy Services in Nursing Facilities

25 SNFs - Focus of 2007 OIG Work Plan
Quality of Care and Licensing Concerns Nursing Home Residents’ Minimum Data Set Assessments and Care Planning Enforcement Actions Against Noncompliant Nursing Homes

26 Assisted Living Facilities
Primarily Private Pay Medicaid Nursing Home Waiver Future State Need to set up systems for monitoring coverage requirements and on-going eligibility Eligible for certain Part A, Part B and HMB benefits in their home Home Health services – Part A/B Hospice Medicare Benefit – ALF = Home

27 Nursing Homes Primarily Medicaid and Private Pay
Medicare Part B Coverage For those NH patients who have exceeded their 100 day SNF benefit, they can receive Part B services, e.g, Rehab Services: Based on Medicare eligibility (enrolled in Part B) Documentation supports medical necessity Physician orders are present and meet reimbursement requirements

28 Question and Answer Session
Janine Boudreau, Janine Boudreau Healthcare Consulting, Inc. Lynda Hilliard, Senior Manager, Life Sciences & Healthcare Regulatory Services,Deloitte & Touche LLP W. Scott Plumb, Senior Vice President, Massachusetts Extended Care Federation Moderated by Lawrence W. Vernaglia, Foley & Lardner, LLP


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