Deadline for SNFs to Dispute Value-Based Penalties Nears — But Some Claims May Be Too Old

Skilled nursing facilities officially have until the end of March to submit corrections related to their quality measure information under the SNF Value-Based Purchasing (VBP) program, which offers incentive payments for facilities that reach certain readmission benchmarks — as well as penalties for those that fail.

But it might not be possible to complete the actual process in certain cases, which involves submitting corrections to the Medicare administrative contractor (MAC), by April 1, officials with the Centers for Medicare & Medicaid Services (CMS) noted on a Wednesday call about the first phase of review and corrections for the SNF VBP program.

“The Phase I corrections — that process began in August[2018] and it ends April 1,” an official from from RTI International, a data contractor with CMS, said in response to a question about claims of unplanned readmission that are more than a year old. “Though there is time left potentially to make an adjustment to a claim … in many cases the timeframe by which you would be able to work with a MAC to make a change has passed.”

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Under SNF VBP program, which took effect in October of last year, SNFs automatically lose 2% of their Medicare reimbursements, with those funds entering an incentive pool. Of that, 60% was set aside to redistribute to SNFs based on performance — with the best SNFs earning back more than the 2% cut — the remaining 40% goes back to the Medicare trust fund, officials said.

CMS ranked all Medicare-certified nursing homes in the U.S., and used a formula to determine incentive payment multipliers that would in turn dictate the Medicare payments. Out of just under 15,000 facilities that reported enough data, 73% had reduced Medicare payments, while the remaining 27% received bonus payments for their reductions of readmissions, though the differences between the best and worst performers were relatively narrow.

SNFs can request corrections for performance information related to quality measures until April 1. But as a questioner on the CMS call noted, mistakes aren’t necessarily the SNF’s fault: Providers can dispute whether or not a hospital readmission during the 30-day observation period was planned or unplanned, which would have an effect on that bonus payment or penalty.

Planned readmissions would not factor into the measure used by the SNF VBP program, but these are determined by claims submitted to CMS, not the Minimum Data Set or patient medical records. And sometimes even a planned procedure might not be enough to make a readmission qualify as “planned.”

“If a planned procedure occurs in combination with a diagnosis that disqualifies a readmission from being considered planned, the readmission will be considered unplanned,” an official said on the call.

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