Are you prepared for a post-pandemic surge of PDPM audits?

More than a year and a half after implementing the Patient-Driven Payment Model (PDPM), how is your skilled nursing facility doing – operationally and financially?

Chances are, you may still not know. The first significant change to post-acute care reimbursement in more than two decades was only a few months old when it – and everything else – was upended by the Covid-19 pandemic. Before most of us had time to adjust, we put PDPM into practice while battling a public health emergency. Talk about building the plane while you’re flying it.

Thankfully, the federal government realized that, without its help, the long-term care industry could be decimated by the pandemic. Relief funds quickly flowed to facilities; regulators agreed to waive long-standing coverage requirements that could block patient access to needed skilled care. And importantly, the Centers for Medicare and Medicaid Services (CMS) also seemed to hold off on facility reviews and audits connected to the PDPM implementation.

That grace period, however, may soon be coming to a close. CMS recently revealed that PDPM – intended to be revenue-neutral as compared to the previous payment model – increased reimbursements to SNFs last year by more than $1.7 billion, raising the specter of potential payment reviews around the corner. And while you may not be seeing PDPM-related additional documentation requests (ADRs) or denials from federal regulators right now, you likely are receiving them from managed care companies. As regulators continue to get caught up after pausing review activity in 2020, they are surely not far behind.

With review activity on the uptick, what can your facility do to stay in compliance and ward off any audits?

  • Accurately assess, then document, document, document

Recent PDPM-related denials from managed care companies often share one thing in common – lack of sufficient documentation about patient conditions.

Under the previous payment model, reimbursement was tied to the amount of care provided. But under PDPM, payments are correlated to individual patient needs – the more complex a patient’s condition, the more reimbursement a SNF receives for providing the patient’s care.

That’s why it is critical for your clinicians and staff to accurately assess each patient’s condition and make sure it is thoroughly documented. This should include an evaluation of the conditions that resulted in the patient’s admission to your facility and any other medical concerns that may affect the patient’s ability to improve while under your care. Don’t underestimate the impact of seemingly unrelated problems, like vision and hearing impairments or dental issues, on your patient’s ability to show progress. All conditions must be identified and documented to paint an accurate picture of your patient’s condition.

All bedside staff need to be trained and re-trained frequently on appropriate documentation methods. Records should indicate why your patient is qualified for a SNF stay, what care the patient will require and what outcome is expected from the recommended treatment interventions.

Additionally, your facility should put systems in place to make accurate and thorough documentation as simple as possible. For example, denials for lack of documentation related to patient functional abilities are common, information that is collected over the first three days of a patient’s stay. However, that can be complicated when the patient has been admitted after normal “business hours” for your key personnel, like nights and weekends. You need to have a process in place to ensure that critical functional information is being continuously assessed and documented, no matter when the patient arrives at your facility.

  • Take the Goldilocks approach

Since reimbursement under PDPM is no longer tied to the volume of care a patient receives, your clinicians should be focused on determining what care is “just right” based on each patient’s potential for improvement. If you’re providing additional care that is unlikely to improve a complex patient’s outcomes, you may draw scrutiny. However, the same can be said if your patient’s characteristics indicate a high likelihood for improvement, but he or she is not receiving necessary care that could encourage improved outcomes. Simply cutting back on the amount of care your facility provides will not keep you under the regulators’ radar.

Most of all, if you do receive notice of an audit or facility review, don’t assume that means you’ve committed fraud or won’t be reimbursed for patient care services you’ve provided. If you’ve created a culture of compliance among your employees and put processes in place to address any identified areas of weakness, you should come out on the other side as a stronger, more compliant facility.

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