The size of the Medicare program is astronomical – the system processes over one billion claims a year. CMS uses several types of contractors to verify that Medicare Fee for Service (FFS) claims are paid based on Medicare requirements. One type of contractor is a Recovery Audit Contractor (RAC). The Medicare FFS RAC Program is one of many tools used to prevent and reduce improper payments. RACs identify and correct overpayments made on claims for health care services provided to beneficiaries, identify underpayments to providers, and provide information that allows CMS to prevent future improper payments.

However, in the past there were numerous complaints about the RAC program. Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals. CMS listened to what providers were telling them and made meaningful changes. That input informed their thinking as they re-examined all aspects of the RAC process. They identified areas where they could reduce provider burden and appeals, and increase program transparency, while enhancing program oversight and effectiveness.

On May 3rd, CMS Administrator Seema Verma, outlined the key improvements and enhancements that were made to the program including:

• Better Oversite of RACs:
  • Accountable for maintaining a 95% accuracy score.
  • Maintain an overturn rate of less than 10%.
  • Contingency fee will be delayed until after the second level of appeal is exhausted.
• Reducing Provider Burden and Appeals:
  • Must audit proportionally to the types of claims a provider submits.
  • Conduct fewer audits for providers with low claims denial rates.
  • Allow more time to submit additional documentation before needing to repay a claim.
• Increasing Program Transparency:
  • Regularly seeking public comment on proposed RAC areas for review.
  • Required enhancements to provider portals for claim status understanding.

While the audits can become cumbersome and overwhelming at times, ensuring that the care being provided is the most appropriate for each individual patient will only continue to assist in getting the health system where it needs to be. The improvements outlined above have helped and will to continue to help make patient care, not paperwork compliance, the main focus of providers.

CMS’ blog regarding recovery audit improvements:

https://www.cms.gov/blog/recovery-audits-improvements-protect-taxpayer-dollars-and-put-patients-over- paperwork

More information on the Medicare FFS Recovery Audit Program can be found at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS- Compliance-Programs/Recovery-Audit-Program/

On Friday, April 19, 2019, CMS released the FY2020 skilled nursing facility (SNF) proposed rule for public inspection and comment.

There is estimated to be a 2.5% market basket increase for FY2020 aggregate payments as calculated through a 3.0% market basket increase and a 0.5% multifactor productivity adjustment resulting in an $887 million annual increase.

The proposed rule includes three proposed changes related to the Patient Driven Payment Model (PDPM). First, CMS proposes changing the definition of group therapy in a SNF setting to match the definition in the IRF setting. Specifically, CMS proposes defining group therapy in the SNF Part A setting as “a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities.”

Second, CMS proposes using a subregulatory process to provide non-substantive updates to ICD-10 codes used in PDPM through the PDPM website, while substantive changes will still be made through the traditional notice and rulemaking process. Non-substantive updates are those made to maintain consistency with the most recent ICD-10 code set. CMS is proposing that this take effect with the start of PDPM on October 1, 2019.

The third and final proposed change is to update the regulation text to reflect changes in the assessment schedule under PDPM which were already finalized in the FY2019 final rule. These changes are to reflect the policy taking effect under PDPM on October 1, 2019. For the initial patient assessment, the proposed regulation changes would state that “the assessment schedule must include performance of an initial patient assessment no later than the 8th day of post-hospital SNF care.” Additional proposed changes to regulation text would reflect the optional interim payment assessment.

SNF Quality Reporting Program

This rule proposes to update the SNF QRP effective October 1, 2020 to include:

• Expansion of data collection for the SNF QRP quality measures to all skilled nursing facility residents, regardless of their payer.
• The addition of two Transfer of Health Information quality measures.
• Exclusion of baseline nursing home residents from the Discharge to Community Measure.
• Public display of the quality measure, Drug Regimen Review Conducted with Follow-Up for Identified Issues.

Request for information (RFI) on the importance, relevance, appropriateness, and applicability measures of standardized patient assessment data elements (SPADEs) for future years in the SNF QRP.

SNF Value Based Purchasing Program

The SNF VBP Program is proposing to change the name of the program’s measure to the “Skilled Nursing Facility Potentially Preventable Readmissions after Hospital Discharge” measure. The measure will retain its previous abbreviation (SNFPPR).

The proposed rule also includes an update to the public reporting requirements to ensure that CMS publishes accurate performance information for low-volume SNFs.

CMS encourages comments from stakeholders. The comment period is open until June 18, 2019.

Download the proposed rule from the Federal Register. Download the CMS fact sheet.

To learn more about Reliant’s preparedness for PDPM, visit our website today.

Every month on the third Thursday, Reliant’s Clinical Services offers a webinar to our partners on relevant topics within our industry.

March’s training Restoring Your Restorative Nursing Program provided participants with information regarding the importance of restorative nursing programs, reviewed the criteria for these programs, and identified strategies for successful implementation.

Join us in April for:
A Deep Dive into the PT and OT Components of the
Patient Driven Payment Model (PDPM)