For its Quality Reporting Program, the Centers for Medicare & Medicaid Services (CMS) is exploring the possibility of expanding nursing home data collection and submission to all residents, regardless of payer type. Officials heard feedback on the challenges and benefits of such a move during a listening session held on Tuesday.
If the federal agency proceeds with such data collection and requires quality measure data submission for all residents, not just those covered by Medicare, officials are interested in understanding the challenges of identifying non-Medicare residents for assessment under the SNF Quality Reporting Program (QRP), among other issues, and in gaining insights into how existing CMS policies in the program can be adapted for broader application.
Challenges stemming from expansion
To that end, CMS officials asked participants whether it was feasible to implement a definition for skilled nursing that would identify non-Part A SNF residents necessitating an minimum data set (MDS) assessment, and what potential challenges might arise from such an initiative. Officials also inquired about the current practices of plans or payers other than Medicare in terms of applying interruption windows when patients are discharged and then readmitted within a specified timeframe.
Participants raised several concerns on these issues, including the complexity of managed care plans rules, the lack of a standardized process, an increased workload, and worries about confusion and a lack of control by skilled nursing facilities (SNFs).
Joel VanEaton, Executive VP of PAC Regulatory Affairs and Education at Broad River Rehab, said that managed care plans have varied interpretations of CMS definitions, making it difficult to standardize assessments across different payers. VanEaton expressed concerns over the complexities that would emerge from managing a diverse patient population, particularly when non-traditional Medicare Part A residents are included in MDS assessments.
“We don’t have a lot of control over the kind of patients that are at the facility that are not traditional Medicare Part A. And so identifying those kinds of residents, and applying this sort of definition would make it more complex to manage the numbers of residents,” said VanEaton. “The definitions would have to change, and the rules would have to change, and the managed care payers would have to get on board with those changes.
On the managed care side, it’s often a third party making those kinds of determinations, he added.
Also, decisions about patient status often involve prior authorizations and other administrative hurdles that the facilities have limited control over, he said.
“And so you’ve got prior authorizations and so forth in there as well. So I think those kinds of things need to be taken into consideration,” VanEaton said.
Other participants posed concerns about the potential increase in administrative burdens for SNFs, with additional assessments required for non-Medicare residents, which may strain resources. They raised questions about how this would strain existing staffing and operational resources, especially since some managed care agreements do not require a five-day assessment.
Meanwhile, some providers also noted the difficulty in managing care for residents under various payer types, especially when decisions about care continuity and discharges are made by third-party payers.
Different insurance companies interpret the stays differently.
Participants also noted that they aren’t confident that managed care organizations (MAOs) will be on board with the changes because “they’re pretty much still going by their own rules.” Oversight of managed care is the greater issue that would need to be tackled before any changes are made by federal agencies on expanding the SNF QRP to all payers beyond Medicare.
Recommendations
While there is interest in improving assessment processes and aligning policies across payer types, significant challenges remain.
The diversity of managed care interpretations and the operational implications for SNFs must be carefully considered before CMS considers moving forward with the changes, participants noted.
In suggesting changes to CMS, participants called for clearer, standardized definitions of skilled services across all payers to reduce confusion. They also said it was important to establish a universal protocol for when assessments should be conducted, making it easier for SNFs to comply with varying payer requirements.
And last but not least, participants urged policy makers to evaluate the administrative burden added from the addition of these policies on SNF operations and make sure that any possible changes will not overwhelm facilities with additional requirements.
Providers and other stakeholders are encouraged to submit additional comments to help CMS make a more informed decision at [email protected].
The email box will remain open for 30 days for additional comments, although the federal agency will not be responding to any comments submitted, CMS officials noted.
Companies featured in this article:
