Medicare Advantage plans forcing providers to take ‘optional’ payment reductions

Many skilled nursing providers are still underusing Interim Payment Assessments under the nascent Patient Drive Payment Model, but one new pressure is driving some to submit those extra patient evaluations even when it will cost them.

Medicare Advantage plans are increasingly insisting that nursing homes submit the optional IPA when a patient’s condition improves and payment would decline — which is not required under any federal regulation.

Centers for Medicare & Medicaid Services memos have confirmed that IPAs are to be conducted at the provider’s discretion. The agency has tried to make clear their voluntary nature multiple times since instituting IPAs as part of PDPM’s launch in October 2019.

Still, reimbursement experts at Zimmet Healthcare Services Group said about 5% of all such assessments they review result in reduced payment, and insurers may be driving some of those needless submissions.

“The IPA is an optional assessment. In the eyes of Medicare, that is very clear,” Zimmet Chief Operating Officer Michael Sciacca said during a webinar last week. “What we’re hearing from some of our clients is that some of the insurance companies are requiring it when there’s a [positive] change in condition, which I would certainly push back on.”

“The requirement to continuously change reimbursement levels, that administrative burden was the whole point of making this assessment optional in the first place.”

Sciacca and Zimmet partner Vincent Fedele, who is also chief operating officer of CORE Analytics, said there continues to be confusion around this — even though some software systems are made to alert and potentially stop providers from submitting IPAs that lower their reimbursement.

Providers could feel compelled to act considering the considerable leverage tha MA plans can, and often do, exert to routinely delay or deny payments.

Too few nursing homes opting in

National consulting firm Proactive Medical Review sees providers skip worthwhile IPAs in roughly 9% of its audits.

“IPAs are often misunderstood and frequently underutilized,” said Stacy Baker, OTR/L, RAC-CT, consulting director of audit services for the Indiana-based firm.  “We often find that IPAs simply aren’t on the radar for the interdisciplinary team. Additionally, with staffing challenges and turnover, some facilities continue to struggle to complete required assessments timely and may have less of an ability to complete the ‘optional’ assessment due to administrative burden.”

Baker said she hasn’t heard of MA plans pressuring providers to submit downward-trending IPAs, but in cases where they are submitted for any reason, Proactive tries to re-educate on their optional nature.

They, like Zimmet, also encourage skilled nursing teams to create processes and teams that know how to track changes in condition that also have the potential to impact payment.

“The facilities that do well and that complete assessments almost twice as much as the average have complex systems in place to identify that change and to understand when there’s a net benefit on the reimbursement side,” Sciacca said. “It speaks to the level of sophistication a facility has in their PDPM management. The whole reason for an IPA is to appropriately reimburse the facility for a change in care. It’s an optional assessment, there’s no penalty if you don’t do one and you’re allowed to miss a significant increase in your reimbursement as well.”

A facility that knows a patient’s nursing component-capture was poor at admission, for example, could be attuned to specific changes that could increase the patient’s need and require more care.

Where the money’s to be made

Sciacca, Fedele and Baker all noted that nursing and non-therapy ancillary components are most likely to be boosted by an IPA. Specific and frequently seen items that could lead to an IPA include isolation transition and the start of IV medications that were not required at admission. 

In SNF settings, Baker also noted surgical wound care, respiratory therapy, new swallowing disorder or mechanically altered diet, or a new diagnosis such as septicemia or pneumonia, or functional changes that impact the GG function score, could precipitate an IPA.

The top 10% of CORE Analytics providers complete IPAs for about 7.1% of charts, which is about 50% more often than the average provider. The average IPA is completed on the 23rd day of the stay and can influence payment for another 24 days prior to discharge. That means a $97 per-diem increase could translate to about $2,300 in marginal revenue, Fedele explained.

Proactive has seen IPA adjustments range from $15 daily to about $100 daily.

Baker noted that pandemic may have made Medicare systems management and MDS accuracy “a lower priority.” Those who continue to deprioritize optional IPAs, however, will continue to lose out.

 “If you are at zero percent IPA completion, you’re probably missing an opportunity,” Fedele said. “It’s very similar to when we used to see zero percent change of therapy in the old system. It was always very indicative of possible miscapture or miscoding.”
Zimmet’s team expects providers to begin completing more IPAs over the next 12 to 18 months as COVID continues to wane and providers learn more about PDPM and understand what reassessments are appropriate.