Having difficulty calculating PDPM revenue and reimbursement? Are you
seeing large credits or debits after your payment has been received? Does
your billing staff have an understanding of the new HIPPS codes? Where to
turn? We have the knowledge.
With payments now routinely rolling in for Medicare status following the
inception of PDPM, there has been a large uptick in PDPM-related billing
questions. While some are specific to a unique problem connected to
technical compliance with consolidated billing rules or the facility’s
accounts receivable software solution, the majority are associated with
uncertainty around the payment and what tools and measurements should be
utilized to proactively predict revenue or monitor incoming reimbursement.
Initially, most providers have seen an increase in their average
Medicare daily rate. Should I be worried we set something up wrong in
With the inception of the PDPM payment methodology, most providers received
an initial “bump” in their payment as a result of the transitional IPAs
that were completed to set up all existing Medicare A covered stays with
billing rates to start and cover payment in October 2019. Because of the
variable per diem incentive associated with the initial three days of a
Medicare A stay, this allowed providers to enjoy a quick influx of cash
that they would not have typically received. While this anomaly is related
specifically to the October transition, to a lesser degree, we still see
those highest rates days (one to three) on every initiated Medicare stay,
so, if there is an increase in admissions and Medicare volume, there will
be an effect.
When put into numbers, the variable per diem (VPD) increases the payment
rate associated with the NTA (non-therapy ancillary) component by a factor
of three times for the first three days of payment. Within the structure of
the NTA, there are six different acuities identified: “NA” through “NF”.
The payment, while regional, sees a swing between these acuities of close
to $200 per day.
When you factor in the VPD, the swing within that rate based on
characteristics of the individual beneficiary can be as much as $1,600!
Even when considering the lowest possible acuities, the additional
$300-$400 dollars adds up. If you started with 15 patients on your Medicare
A caseload on October 1,2019 at the lowest rate you would have seen a
positive bump of approximately $4,500 right out of the gate.
What are some of the techniques to make sure our staff can verify
Help your team by giving them the tools to succeed. We recommend a solid
triple check format to ensure your team is confirming the services provided
and providing the documentation needed to support the billing. At a
minimum, this triple check should include the biller who generates the
claim, the MDS Coordinator (the person responsible for the diagnosis
coding/sequencing) and a therapist to validate the types and frequency of
therapy. With the release of the Final Rule prior to the October 1, 2019
start, new therapy thresholds were implemented that cap the overall
utilization of an individual’s therapy program at no more than 25 percent
of their total treatment plan comprised of concurrent OR group therapy. This is calculated at the end
of the Medicare A stay and reported to CMS via the end of PPS Assessment.
The table below represents the necessary checks and balances you should
verify against the claim.
Another tool that leads to the best reviews when quality checking your
information for accuracy, is the use of a PDPM rate calculator. There are
many rate calculators on the market that give you the ability to predict
the rate based upon the CMG score derived from the MDS. These calculators
are available for purchase, can be found online as “freeware”, are offered
by many of your state health care association advocacy groups, and are also
embedded within many of the long-term care electronic software programs.
For efficiency and accuracy, find one that allows for specification by
geographic region and considers the facility’s current rankings within the
Value Based Purchasing program.
We have the tools and we have the people!
It’s a whole new world and there is much to learn. PDPM represents a new
method of payment that keeps all healthcare providers focused on what’s
best for the industry. This culture shift will enable providers to bring
value to their patient populations and ensure the payment associated
represents that philosophy. While this is the new normal in post-acute
healthcare services, we must recognize that it requires a different level
of understanding and impacts all aspects of operations. Teams, health
providers and healthcare billers must work together and collaborate to
operate successfully within our industry.
To learn more about the services offered by Beacon Solutions Group, please
contact our Beacon experts today.