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Take it to the Next Level Under PDPM - Five Smart Reimbursement Practices

When it comes to clinical reimbursement opportunities, HealthPRO® Heritage asks: “Is your clinical team leaving no stone unturned?” As national healthcare consultants with a progressive approach to PDPM, HealthPRO® Heritage offers five simple (but not easy*) strategies to compliantly optimize clinical-based reimbursement.

"If it were easy….then everyone would do it!"

#1: How can SNFs optimize cash flow?
Three words:  Rapid billing cycle.

CMS pays their bills on time, so why not accelerate billing file submission and related quality assurance to optimize cash flow? 

HealthPRO® Heritage recommends IDTs come together for a formal pre-transmission review to assure all opportunities were captured accurately on the MDS. This important step assures that by end of month – when the UB’s are drafted – the IDT is 100% certain of what’s been captured so claims can be submitted quickly. The Triple-Check process is a MUST! HealthPRO® Heritage uses a comprehensive checklist to assure all pertinent data is cross-referenced and accurate.

#2: How can facilities improve capture of NTA & Nursing criteria?
With each admission, do a thorough discovery of all active diagnoses and comorbidities, and identify how to manage care planning areas. Doing so will allow for expanded capture of the Nursing CMG category, if indeed it is in-step with NTA capture. HINT: Comprehensive education for nursing teams on PDPM success drivers, skilled documentation, and retooled workflow will prove out to be very valuable!

Our teams use a proprietary PDPM Profiler 1.0 (to guide/educate IDT through a detailed, stepwise process) or an updated, more streamlined version (PDPM Profiler 2.0) to ensure documentation accurately reflects / supports care and active diagnoses. Also, ongoing IDT collaboration and a much-need check-and-balance approach is supported with HealthPRO Heritage’s New Clinical Daily Meeting.

#3: What common coding practices don’t accurately reflect patient characteristics and therefore continue to limit reimbursement potential?
HealthPRO® Heritage has completed hundreds of audits since October 2019, and we continue to see easy-to-address trends that represent opportunity for improved reflection of accurate patient characteristics and, hence, reimbursement, such as:

  • Improved CMG mapping with increased specificity for the Principal diagnosis. Ask: Does what you chose (which may or may not be the admitting diagnosis) truly reflect the reason for the skilled stay?
  • ARDs that reflect IV nutrition capture for more appropriate Nursing CMG
  • Improved documentation to capture Respiratory Therapy, COPD with shortness of breath while lying flat
  • Capturing NTAs in i8000 that are not checkboxes
  • Thorough investigations for Malnutrition and Morbid Obesity (Tune in: The Strategy Academy podcast for more on these NTA items!)

Need more support for compliant, accurate and optimal coding?  HealthPRO® Heritage has partnered with himagine Solutions to offer the SNF industry the only outsourced virtual coding service. Learn more here.

#4:  Continue to break down silos!
Every IDT staff member has vital information to contribute to the overall picture of the patient, so be sure an efficient process and workflow is in place to capture all relevant clinical details. Specifically, HealthPRO® Heritage consultants are seeing lots of opportunity for improved:

  • GG collaboration;
  • Swallowing disorder capture during meals and med passes;
  • Communication of order changes; and
  • Identification of diagnoses that continue to require disease management. Pause and take a moment to re-evaluate your practices. 

Ask: Is the IDT leaving opportunity on the table? Are IPA opportunities being identified proactively?   Are you getting credit for all of the resources being devoted?

#5: Ask:  ‘What’s next?’ What changes are likely for CMS’ Proposed Rule that will impact reimbursement?
Perhaps as soon as October 2020, several changes are proposed for the MDS (Learn more: Read this blog post or listen to this podcast) that prioritize patient-centered care and continue to align SNF reimbursement with important initiatives (e.g.: hospital readmission mitigation). 

Ask: How well is your team performing on important initiatives TODAY, and are you well-prepared for how this next round of CMS changes will shape reimbursement opportunities in the future?   Savvy SNFs must evaluate what resources and process redesign will be necessary to optimize tomorrow’s bottom line outcomes. 

HealthPRO® Heritage is focused on strategies to assure positive outcomes in 2020 & beyond, and we promise to continue to share best practices and lessons learned. 

Tags: LTC, Patient-Driven Payment Model, PDPM, CMS Update 2020