Almost a year after the implementation of Medicare’s Patient-Driven Payment Model (PDPM), the Medicare rate of reimbursement for each facility is derived from these five care components: physical therapy, occupational therapy, speech-language pathology, non-therapy ancillary (NTA), and nursing. Skilled nursing facilities may be missing some key payment drivers, with the result of “leaving money on the table,” as some would describe.
According to some healthcare consultants, depression represents one of these newly reimbursement-sensitive conditions, and it is described as a possible “linchpin” for PDPM success. It is estimated that under PDPM, “a facility could see an increase in payment of about $43 per day for treating depression as part of a resident’s overall care plan,” which would result in additional income of around $870 over a 20-day stay.
Training frontline caregivers regarding the signs of depression among residents in skilled nursing facilities is key to success under PDPM. For many reasons, skilled nursing facilities may not have been particularly proactive regarding the importance of identifying depression in residents, but recognizing the financial benefit may provide an impetus to improve diagnosis and care.
Another positive aspect, other than the specific PDPM reimbursement gains connected to depression, is the positive “trickle-down” effect related to the visibility that nursing home metrics related to quality of care demonstrate. Also, residents with depression generally have longer lengths of stay due to their need for more attention and longer recuperative time periods.
Cognitive impairments represent another widely underreported condition, and providers that fail to identify cognitive impairments could be losing up to $21 per day, along with overlooking the effect on lengths of stay and the avoidance of expensive rehospitalizations.
It should be pointed out, however, that the extra dollars derived from such increased payment rates should be dedicated to residents’ direct care needs and not simply become pure reimbursement drivers.
Compliance Perspective
Issue
Failing to adapt to the changes in the Medicare reimbursement process for a nursing home under PDPM by taking a proactive position to consider areas of care that constitute reimbursement-sensitive conditions, like depression, could result in submitting incorrect claims, and even “leaving money on the table.” This can result from overlooking key care areas that are also payment drivers, which may jeopardize the resident or even the financial stability of a facility, and could ultimately result in it having to make program of staffing cuts or even close its doors.
Discussion Points
- Review policies and procedures regarding the five care components in PDPM to explore potential key reimbursement-sensitive drivers.
- Train staff members to recognize the signs of depression so that residents receive the treatment they need, and that potential reimbursement-sensitive conditions are supported by documentation of medically necessary diagnoses and related care.
- Periodically audit to determine if claims submitted under PDPM adhere to guidelines for the five care components.
