Transcript Document

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
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Moderated by Lawrence W. Vernaglia, Foley & Lardner, LLP
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
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
Industry Overview
Provider Payer Mix Comparison
Nursing homes are uniquely dependent upon Medicaid
to provide quality health care
Nursing Home Payer Mix
Private Pay
15.0%
Home Health Payer Mix
Other Payers
(Insurance, Hospice)
1%
Private Pay/Other
17%
Medicare
15.9%
Medicaid
68.1%
Medicare
49%
Acute Hospitals Payer Mix
Private Pay
40%
Other
7%
Medicaid
12%
Medicare
41%
Medicaid
34%
The Nursing Facility “Dollar”:
Breakdown of Nursing Home Spending
Salaries and benefits represent 71 cents of every dollar spent by
nursing facilities
General
Expenses/Operating
(Supplies, Food,
Utilities &
Liability Insurance)
Physical Plant
(Mortgage and
Property Taxes)
Administration (Administrator, Accounting,
Clerical)
$0.06
$0.10
$0.13
All Staff Wages &
Benefits
$0.71
Based on Division of Health Care Finance and Policy nursing facility cost reports
50,000 Nursing Facility Employees
The nursing facility provider community is a major economic
engine
Social/Medical
and is the largest
employer in some communities
7% Social/Medical
Administrative
8%
Housekeeping
6%
Laundry
3%
Maintenance
2%
32,000
Dietary
10%
Source: DHCFP Nursing Facility Annual Cost Reports
Direct Care Nursing
Staff
64%
Nursing Facility Direct Care Nursing Staff
Median Wage Increases:1999–2006
Nursing facilities are good employers
Average annual increase of 4.2%
3.0%
$18
4.1%
$16
7.9%
4.6%
$14
$12.64
$14.87
3.8%
$15.44
3.0%
$15.90
3.1%
$16.40
$16.88
$14.28
$13.23
$12
$10
$8
$6
$4
$2
$0
1999
2000
2001
2002
2003
2004
2005
Sources: MECF Annual Wage Surveys 1999-2006
2006
3,700 Nursing Facility Direct Care
Staff Vacancies
Despite Investment in Staff Wages & Benefits, Significant Vacancies Exist
Certified Nurse Aide
Registered Nurse
1,100
1,800
Licensed Practical
Nurse
800
Sources: DHCFP Annual Nursing Facility Cost Reports and MECF Annual Wage Surveys
Average Daily Minutes of Nursing Care
Reimbursed By Medicaid*1
Unaudited Management Minutes
Moving Average MMQ Score
200
196.3
197.0
194.2
195
190.6
190
185.9
185
180
175
FY95-97
FY98-00
FY01-03
FY04-06
FY07
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).
Medicaid Nursing Facility
Resident Acuity – 2006
Nearly all nursing home residents require extensive nursing care
% of Total
Medicaid
Residents in
Case Mix
Category
30%
26.0%
24.0%
25%
20.0%
20%
15.0%
15%
13.0%
10%
5%
3.0%
0%
Category 1 Category 2 Category 3 Category 4 Category 5 Category 6
MMQ Category
H
J,K
L,M
N,P
Minutes (Range)
30
30.1 – 110
110.1 – 170
170.1 – 225
Minutes (Median)
30
81
142
199
Source: MassHealth Unaudited Management Nursing Minutes Score
R,S
225.1 – 270
244
T
270.1+
288
Nursing Facility MEDICAID
UNCOMPENSATED CARE Per Day, 1999-2006
$500,000 annual Medicaid loss per Medicaid participating nursing facility
$25
$21
$20
$15
$21
$20
$18
$18
$15
$16
$16
$10
$5
$0
1999
2000
2001
2002
*2003
2004
2005
2006
(Proj)
Sources: 1999-2004 BDO Seidman Reports; MECF Estimates 2005-2006
*User Fee Program Implemented (2003); User Fee Program Maintained In Subsequent Years
Consumer Satisfaction in
Massachusetts Nursing Homes
Independent state survey shows nursing facility consumers are highly
satisfied
% of
nursing
homes
100
90
87%
80
70
60
50
40
30
13%
20
10
0
Consumers
who are:
0%
Very Satisfied
Satisfied
Neutral
0%
Dissatisfied
0%
Very Dissatisfied
Source: Massachusetts DPH Nursing Home Satisfaction Survey Results, December 2005
Nursing Facility Spending As a Percentage
of Total Medicaid Spending: FY1999-FY2006
% of Total
Medicaid
Spending
32
31.5%
31
30.1%
30
29
28.2%
28
26.4%
27
26
25.7%
25.6%
24.3%
25
24
22.5%
23
22
1999
2000
2001
2002
2003
2004
2005
Sources: SFY 1999-2004 Actual (MassHealth Budget Office); SFY 2005-FY2006 Massachusetts
Taxpayers Foundation (April 2005 Report, p.14) and MECF Nursing Home Data
2006
Continuum of Long Term Care
At Home:
Routine Care
At Home:
Informal Support
► Short
Term Care
► Hip
Fractures
► Knee Replacements
► Stroke
► Cardiac Disease
At Home:
Formal Support
► Long
Assisted
Living
Term Care
► Alzheimer’s
Disease
► Advanced Dementia
► Multiple Illnesses
► Congestive Heart
Failure
► Advanced Diabetes
► Neurological (MS,
Severe Brain Injury)
► Hospice
FacilityBased Care
High Level Revenue Cycle
Pre-Admission Checklist
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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
Payor Mix
► Medicare
► HMO/Managed
► Private
► Medicaid
Care
Special Populations
► Palliative
► Hospice
► HIV
Billing Cycle
► Pre-billing
for:
 Private
 Patient Paid Amount (PPA)
 HMO/Managed Care
►Prior
Authorization
 Medicare/Medicaid
►Verifying
level prior to actual billing
Rebilling and Reconciliation
► Credit
Balances
► Adjustments
► Denied or Suspended Claims
Reimbursement Compliance Issues
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
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
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
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
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
Question and Answer
Session
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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