Why is my reimbursement less than the published Medicare rate?

There are multiple factors that are impacting facility rates this year, and it can be quite confusing.

First, there is 2% withheld to fund the value-based purchasing (VBP) program, but that is already built into the rates. Next, there is 2% withheld for sequestration, which should be built into your AR program to automatically adjust the rates in your system. 

The next step is to apply your incentive multiplier that is listed in your SNF VBP Scorecard. This should give you your current rates, unless you received a CMS Determination of Non-Compliance letter in late summer 2018. That will remove an additional 2% from your reimbursement.  

The determination of non-compliance comes from not meeting the thresholds from the required VBP submission data. The required submission data is both claims-based and MDS-based. MDS-based data includes: Falls with Major Injury (J); An Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (GG), and New or Worsened Pressure Ulcers (M). 

As of October 1, 2018, also being measured are: Drug Regimen Review Conducted with Follow-Up for Identified Issues (N), Change in Self-Care Score for Medical Rehabilitation Patients (GG), Change in Mobility Score for Medical Rehabilitation Patients (GG), and Discharge Mobility Score for Medical Rehabilitation Patients.

The Percent of Residents with Pressure Ulcers that are New or Worsened has been replaced by Changes in Skin Integrity Post-Acute Care Pressure Ulcer/Injury. (M). Remaining  unchanged are: Discharge to Community Medicare Spending Per Beneficiary, and Potentially Preventable 30-Day Post- Discharge Readmission.

Please send your payment-related questions to Caryn Adams at ltcnews@mcknights.com.