Providers Must Lay Groundwork Now for Coming Payment ‘Game Changer’

The Centers for Medicare & Medicaid Services (CMS) hasn’t yet announced complete details about upcoming changes to therapy reimbursements, but that doesn’t mean skilled nursing facilities should wait for word on the sidelines.

“In general, we really need to consider redesign — care redesign — because what you’re doing today, and I say that obviously in general, may not fare as well with this system,” Elisa Bovee, vice president of clinical strategies at therapy management and consulting firm HealthPro Heritage, said at LeadingAge Illinois’s annual conference in Schaumburg, Ill. on Wednesday.

Under the new therapy reimbursement system — the Resident Classification System, Version I (RCS-I) — providers will see their reimbursements determined by achieving quality goals and taking on more complex patients, as opposed to the current fee-for-service model.


That means providers can no longer simply boost their revenues by billing for as many therapy hours as possible under the law, and must increasingly rely on group therapy to maximize reimbursements.

An analysis from health care investment bank Cain Brothers & Co. called the coming payment shift a “game changer” for the skilled nursing industry.

“The winners of RCS will be the organizations that move away from the antiquated minutes-based approach to care toward a holistic care environment,” Cain Brothers associate Joshua Zenilman wrote earlier this month. “These will be the facilities that attract the more complex patients, and CMS will reward them accordingly.”


About 85% of providers currently do not provide group therapy, Bovee estimated, and CMS will continue to incentivize volume until the change takes effect, which likely will not occur until late 2019. But establishing a precedent now will help ease the process down the road, Bovee said, as well as prepare residents for the change.

Deb Reardanz, president and CEO of the Clark Lindsey continuing care retirement community (CCRC) in Urbana, Ill., said that adjustment of expectations is key, and should be communicated to incoming and current residents and their families.

Clark Lindsey, which has 105 skilled nursing beds in addition to independent and assisted living and other services, recently embarked on a plan to expand its Medicare-reimbursed nursing population. As part of that initiative, the non-profit elected to split its post-acute and long-term care operations into separate units, each with its own director of nursing — with the goal of making sure the hospital feel of the post-acute section didn’t leak into the LTC setting, which Reardanz said “feels more like home.’

As part of the push, Clark Lindsey sought to change therapy partners, eventually selecting HealthPro Heritage. During that process, Reardanz said, many potential providers didn’t express a clear enough game plan about the new rule changes — highlighting the importance of mastering the nuances well before the changes take effect.

“Most companies can provide a great service to the patients — we have very high satisfaction rates — but what we weren’t getting were strategic questions about: How are you preparing for RCS?” Reardanz said of the process.

The facility also made a concerted effort to identify local acute providers’ pain points, specifically seeking out information about specific billing codes that were problems for area hospitals.

“We have our own data, [and we] try very hard to get in front of people and show them what the data says,” Reardanz said.

As of April 1, Clark Lindsey had boosted its Medicare population from 25 to 37 beds, filling the available slots on the same day they became offered.

“There’s a great demand for our beds, which is a good place to be,” Reardanz said.

Written by Alex Spanko

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