Expert Nursing Services (SNFs) present a priceless service to communities, assembly the wants of individuals with advanced medical circumstances who require short-term rehabilitation or longer-term care. Sadly, SNFs are navigating an more and more difficult operational atmosphere formed by shrinking capability, workforce shortages, new fee fashions, rising prices, and regulatory pressures. The shift from conventional Medicare to Medicare Benefit, mixed with insufficient Medicaid funding, has resulted in income not conserving tempo with larger prices associated to staffing challenges and inflation. Conversely, altering demographics and evolving market calls for are opening the door to new income streams and care fashions.
To stay resilient amid the volatility, SNFs want to remain on high of what’s impacting operations and take into account strategic alternatives. Listed here are essential developments to look at.
The inexorable transfer in the direction of worth
The shift towards value-based fee (VBP) in Medicare and Medicaid continues. To safe reimbursement in these fashions, SNFs should persistently display constructive high quality outcomes, comparable to diminished hospital readmissions, enhanced affected person satisfaction, and higher long-term resident well being.
SNFs that do effectively in these fashions relentlessly concentrate on high quality; have a plan for understanding and enhancing key metrics; and designate some extent particular person or crew to guide high quality enchancment efforts. They incorporate high quality measures of their dashboards and talk about them together with benchmark information that reveals how they examine with friends.
Even outdoors of VBP, there are quite a few advantages to creating high quality enchancment a precedence. Sturdy high quality outcomes help with contracting, reimbursement, advertising, and even household satisfaction. They’ll additionally make a SNF extra enticing for accountable care group participation or hospital partnerships.
The shift to Medicare Benefit (MA)
Medicare Benefit enrollment continues to outpace conventional Medicare Half A, inflicting challenges for post-acute care suppliers. In contrast with conventional Medicare, MA plans sometimes have shorter lengths of keep, decrease reimbursement, and a extra cumbersome preauthorization course of.
Constructing sturdy relationships with space hospital networks and doctor teams can drive admissions to a SNF’s location, which can assist counterbalance a few of MA’s challenges.
SNFs ought to join with the MA plans of their market to evaluate reimbursement charges. Some plans haven’t elevated supplier charges just lately, which presents alternatives for SNFs to proactively attain out to barter larger charges. SNFs which might be ready to indicate constructive high quality outcomes, together with diminished hospital readmissions and strong CMS 5–star rankings, are extra seemingly to achieve success with these conversations.
The transfer to the Affected person-Pushed Fee Mannequin (PDPM) for Medicaid
In October 2019, SNFs transitioned from the volume-based RUG-IV reimbursement mannequin to the Affected person-Pushed Fee Mannequin for his or her Medicare reimbursement. Most SNFs made the shift easily, and by early 2020, have been well-versed within the new fee mannequin. Now, the vast majority of states are shifting to PDPM for Medicaid by the tip of 2025, and this transition could show extra advanced. Knowledge means that the case combine index below Medicaid PDPM is decrease than it was below RUG-IV.
Many states are phasing in Medicaid PDPM to offer organizations time to totally perceive learn how to full the brand new mannequin’s minimal information set and assess the associated impression to their Medicaid reimbursement. This additionally provides the state Medicaid applications time to regulate their calculations and reimbursement methodology, if wanted. SNFs that haven’t but adopted the Medicaid PDPM would profit from connecting with friends in different states, who could provide classes discovered and finest practices to ease the shift.
Better scrutiny for Payroll-Based mostly Journal (PBJ) reporting
Whereas there’s been enchancment, SNFs proceed to battle with staffing shortages. This coupled with elevated scrutiny of Payroll-Based mostly Journal (PBJ) submissions, implies that SNFs ought to be ramping up their PBJ accuracy and reporting efforts.
PBJ submissions have an effect on a corporation’s star ranking. When a SNF misses the deadline or the info is considerably inaccurate, it may end up in a 1-star ranking for staffing, which reduces the group’s total 5-star ranking. This could negatively impression managed care contracting, referral supply relationships, and Medicaid reimbursement for these applications that tie fee to star rankings.
Staying vigilant to reporting deadlines is important. Many organizations miss the PBJ submitting date or ship inaccurate staffing information as a result of they lack an applicable inner course of. Having a couple of particular person concerned within the PBJ submission, establishing calendar reminders, and using a PBJ targeted software program are comparatively straightforward methods to keep away from lacking the deadline. Reviewing PBJ studies effectively prematurely of the due date can be sensible to permit ample time to verify information accuracy and make the suitable changes.
Diversified income streams
As margins tighten, SNFs are starting to discover extra income alternatives, comparable to short-term rehabilitation services, ventilator items, dialysis providers, and reminiscence care areas to record a number of.
Earlier than pursuing a brand new service, a SNF should first perceive the market, whether or not there are underserved wants, and who the opponents is perhaps. A corporation can collect this info from discussions with hospital referral sources in addition to contemplating a market examine to know demographic information together with hospital DRGs and discharge information.
The group also needs to suppose by operational logistics. What scientific ability set or capabilities can be required? Are there particular certifications, bodily area necessities, or tools wants? How would the census and payor-mix be affected?
Potential reimbursement ought to be a consideration as effectively. Is there larger reimbursement by Medicare? Is there extra reimbursement by a state Medicaid program, comparable to for ventilator providers, reminiscence care or behavioral care?
Gathering and analyzing this information could appear daunting. That is the place a third-party may very well be helpful, gathering and deciphering info to assist make an knowledgeable choice.
Institutional Particular Wants Plan (I-SNP) participation
I-SNPs current one other income stream alternative, emphasizing high quality, with the aim of conserving people wholesome and minimizing pointless hospital stays.
An I-SNP sometimes supplies a nurse practitioner enhanced know-how and entry to finest observe scientific pathways, which may strengthen a corporation’s scientific operations. Suppliers that take part in an I-SNP could also be eligible to obtain bonus funds in the event that they obtain designated high quality benchmarks.
Residents profit from I-SNP participation as a result of these plans are designed for the nursing residence business. Whereas an ordinary managed care plan could provide health club memberships or different perks designed for lively seniors nonetheless dwelling at residence, an I-SNP could provide SNF-focused advantages, comparable to dental, or free barber and sweetness providers.
All SNFs ought to consider the potential for I-SNP participation. Due to the standard emphasis in these applications, they typically enhance long-stay outcomes, which may present a further benefit if the SNF is a part of a state Medicaid program that has a value-based or quality-based reimbursement part. Participation in an ISNP permits the supplier to share within the monetary rewards for attaining strong scientific outcomes vs the upside solely going to the MA group.
A strategic method is important
SNFs are going through a interval of nice change, pushed by rising fee fashions, price pressures, and rising calls for for providers. This atmosphere requires clear priorities and a strategic plan that connects day-to-day efforts to long-term objectives. When steady concentrate on high quality enchancment is foundational to the plan, SNFs can place themselves to adapt, compete, and thrive each now and within the years forward.
Photograph: baona, Getty Pictures
Denise Leonard is a Companion and CPA at Plante Moran, based mostly in Cleveland, Ohio. With over 25 years of expertise within the healthcare business, she focuses on aiding post-acute healthcare organizations — together with expert nursing services, ICF/IIDs, hospital-based SNFs, persevering with care retirement communities, and residential well being and hospice suppliers — to navigate the evolving panorama of healthcare reimbursement. Denise’s experience lies in optimizing income cycle processes and creating strategic options that place organizations for achievement. Denise acquired her B.A. in accounting from the College of Akron. She is a member of the American Institute of CPAs (AICPA) and serves on the advisory board of Welcome Home, a corporation devoted to supporting people with developmental disabilities.
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