You’ve surely already heard your organization should brace for an adjustment that brings the Patient Driven Payment Model back to budget-neutral status.
Well, it may be time to go ahead and buckle up.
The feds have said that the shift to the new payment system in October 2019 inadvertently triggered 5%, or $1.7 billion, more spending than was intended, and that the Centers for Medicare & Medicaid Services would have to dial that back.
Lest you think it might be a good long while until you feel the pain, think again.
If you work with managed care, chances are pretty good you’re already on a collision course set in motion by the federal government broadcasting future cuts.
“CMS hasn’t kept that quiet, and guess who else has heard that information? That would be all the managed care organizations,” Susie Mix, CEO and president of Mix Solutions Inc., warned in May. “Just when we thought managed care would give us some type of break for just a quick second, they seem to always add some type of insult to injury.”
In this case, they’re already pivoting away from contracts they forged at the advent of PDPM, when they largely agreed to pay skilled nursing providers rates comparable to those in the new model.
Now, health plans are taking the CMS “overpayment” indictment and running with it, pushing providers into levels-based contracts that drive reimbursement down to 90% of PDPM rates — in the best cases.
Mix said many managed care entities will pressure providers to convert by late 2021. She urged providers to make plans, understand the specifics of their contracts and figure out how to maximize them before beginning to admit patients whose coverage could cost unprepared facilities.
The plans “are very aggressive in not only cutting our rates 30% to 40%, but they’re also very aggressive in starting this right now,” she said.
Mix, who has been negotiating nursing home contracts for nearly two decades, said she has never seen “so many health plans on the same page at the same time.”
So even if CMS honors its word and takes providers’ input into consideration and rolls back PDPM rates over several years, don’t you dare expect managed care to take its sweet time.
Otherwise, Mix warned, you might be holding more of the bill than even CMS could imagine.
