Over the years, anytime a significant regulatory change has occurred in the SNF industry, the software solutions providers have sprung into action to ensure the functionality is in place for their customers.  These software solutions providers are used to dealing with annual changes associated with the MDS & always having these updates running by October 1st, which coincides with the beginning of the Medicare fiscal year. The Patient Driven Payment Model, (PDPM) is targeted for October 1, 2019, and is the most significant change to reimbursement we have seen since MDS 3.0.

Today we look at 4 PDPM issues related to billing that, when speaking with your software solutions providers, will help SNF operators ensure preparedness and implement any new workflows.

1. Ready for the “Hard Switch?”  – On a recent Medicare Learning Network call, CMS officials advised the audience that there would be no transition period from RUG-IV to PDPM.  Instead, the “hard switch” will occur on 10/1/2019.  RUG-IV rules will be in effect until 9/30/2019.  PDPM rules on 10/1/2019. MDS Coordinators will need to lead the charge to ensure accuracy and compliance when it comes to MDS Assessments.

2. What about Medicare Advantage?  – Medicare Advantage plans typically reimburse SNFs according to either a RUG score or Level of Care.  CMS will continue to leave this up to the individual payors, thus increasing the level of complexity for the providers.  Operators should proactively engage the individual Medicare Advantage plans and discuss their PDPM transition plan.  From a software perspective, the providers will need to ensure the setup of the payors in the back end of the billing system will allow for the continued production of clean claims.

3.  How about PDPM scores? – Under the current RUG-IV system, the coding of the MDS for Medicare patients produces one of 66 RUG categories for billing.  Starting 10/1/2019, a PDPM HIPPS code will be produced. Engage your billing team early, and run parallel so there are no surprises, especially with tight cash flow margins.

4. What about the LTC population? – Recently CMS announced that on October 1, 2020, they will no longer support RUG-III and RUG-IV case-mix methodologies, which are used by many states for Medicaid CMI.   CMS has recently announced that they have created an optional state assessment (OSA) to use during Fiscal Year 2019.  If you are in a Case Mix state, it is critical that your software provider can support you through this change.

Exciting stuff!  I’m sure there’s so much more to cover, & hopefully, I helped you get the ball rolling.  If you’d like to share some thoughts, please use the comment box below.