Here’s what we know about RCS-1 & rehabilitation services.

Goodbye, RCS-1. Hello, PDPM. Here’s What to Know About Rehabilitation Services

Rehabilitation therapy providers and SNF administrators have followed the news with interest regarding the proposed October 2018 (FY 2019) implementation of a new system by which to calculate payments for services.

This was a new reimbursement model proposed by the Centers for Medicare and Medicaid Services (CMS).

Over the past year, stakeholders from across the spectrum shared concerns and objections to the proposed overhaul of the existing payment model. Due to those concerns and continued efforts at refining it, numerous changes have been made to the original proposed guidelines.

In fact, the new changes have prompted a new revamped reimbursement model: The SNF Patient Driven Payment Model (PDPM).

October 2018 Changes With PDPM & Rehabilitation Services

PDPM is effective Oct. 1, 2018. Skilled Nursing Facilities will have one year to transition from RUG-IV to PDPM, to meet the October 1, 2019 date for implementation.

The overall goal of PDPM is to change the way therapy providers deliver therapy to SNF residents.

Beginning Oct. 1, 2018, SNFs that fail to submit quality data will face a 2 percent reduction in their payment rate for that fiscal year (FY). The Centers for Medicare & Medicaid Services announced that these reporting-based reductions will not be cumulative and will only apply to the fiscal year involved.

Skilled Nursing Facilities who fail to comply with the QRP requirements will receive a notification letter from their MAC.

SNFs receiving this letter will have the opportunity to submit a request for reconsideration if they disagree with the noncompliance decision. Instructions for submitting requests for reconsideration can be found on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

Beginning Oct. 1, 2018, SNFs will have an opportunity to receive incentive payments based on performance on the specified quality measure. CMS will withhold 2 percent of SNF Medicare payments starting Oct. 1, 2018, to fund the incentive payment pool. They will then redistribute 50–70 percent of the withheld payments back to SNFs through the SNF VBP Program.

Hospital readmissions within 30 days count against the SNF whether the resident is re-admitted directly from the SNF or after discharge, as long as the resident was admitted to the SNF within one day of discharge from a hospital stay. Planned readmissions are excluded because they do not indicate a poor quality of care.

The New Patient-Driven Payment Model & Rehabilitation Services

The CMS final rule outlining Fiscal Year 2019 Medicare payment updates and quality program changes for SNFs, issued on July 31, 2018, seeks to “continue a commitment to shift Medicare payments from volume to value.”

CMS’ new case-mix model, called the Patient-Driven Payment Model (PDPM) becomes effective on October 1, 2019. It seeks to improve incentives that shift focus to treating the patient’s condition and specific care needs.

This will determine Medicare payment, as opposed to basing reimbursements on the amount of care provided. It will also significantly reduce the amount of paperwork and overall complexity of tracking specific service volume.

Basic features of the PDPM case-mix model include:

  • A focus on clinically relevant factors (as opposed to volume) by using ICD-10 diagnosis codes and patient characteristics as the basis for patient classification
  • Medicare payments adjusted based on each aspect of a resident’s care, more accurately addressing costs associated with medically complex patients
  • SNF per diem payments adjusted to reflect varying costs throughout the stay and incorporate safeguards against potential financial incentives to ensure that beneficiaries receive care consistent with their unique needs and goals
  • A new combined limit on group and concurrent therapy of 25 percent, to better attune therapy services to each resident’s individual needs and goals (with promises to consider further adjustments for flexibility)
  • An approximately 80 percent reduction in the number of payment group combinations compared to the RCS-I
  • Greater use of certain standardized items for payment calculations than RCS-1, such as in using function items also used for the SNF QRP
  • Simplified paperwork requirements for performing patient assessments by reducing reporting burden

It is encouraging that CMS continues to listen to stakeholders and adapt the new system to allow SNF healthcare providers to be fairly compensated for providing excellent care. As changes continue to roll out, therapy service providers must stay on top of things in order to meet the newest guidelines.

Apex Rehab and Regulation Changes Relating to Rehabilitation Services

At Apex Rehab, we stay on top of regulatory and guideline changes in order to help our partner SNFs prepare for and meet those changes. With more changes coming as stakeholders continue to share concerns, Apex Rehab will follow the updates and keep you up-to-date on the latest as time passes.

Apex Rehab helps Skilled Nursing Facilities understand and implement regulatory changes like RCS-1 and PDPM that will affect therapy services. To learn how we can help your SNF, call (412) 963-9698 or contact us online.