Expert Nursing Services (SNFs) present a worthwhile service to communities, assembly the wants of individuals with advanced medical circumstances who require short-term rehabilitation or longer-term care. Sadly, SNFs are navigating an more and more difficult operational atmosphere formed by shrinking capability, workforce shortages, new cost fashions, rising prices, and regulatory pressures. The shift from conventional Medicare to Medicare Benefit, mixed with insufficient Medicaid funding, has resulted in income not conserving tempo with increased prices associated to staffing challenges and inflation. Conversely, altering demographics and evolving market calls for are opening the door to new income streams and care fashions.
To stay resilient amid the volatility, SNFs want to remain on high of what’s impacting operations and take into account strategic alternatives. Listed here are essential tendencies to observe.
The inexorable transfer in the direction of worth
The shift towards value-based cost (VBP) in Medicare and Medicaid continues. To safe reimbursement in these fashions, SNFs should constantly reveal optimistic high quality outcomes, resembling decreased hospital readmissions, enhanced affected person satisfaction, and higher long-term resident well being.
SNFs that do nicely in these fashions relentlessly give attention to high quality; have a plan for understanding and enhancing key metrics; and designate a degree individual or group to guide high quality enchancment efforts. They incorporate high quality measures of their dashboards and talk about them together with benchmark knowledge that exhibits how they evaluate with friends.
Even exterior of VBP, there are quite a few advantages to creating high quality enchancment a precedence. Sturdy high quality outcomes help with contracting, reimbursement, advertising, and even household satisfaction. They’ll additionally make a SNF extra enticing for accountable care group participation or hospital partnerships.
The shift to Medicare Benefit (MA)
Medicare Benefit enrollment continues to outpace conventional Medicare Half A, inflicting challenges for post-acute care suppliers. In contrast with conventional Medicare, MA plans usually have shorter lengths of keep, decrease reimbursement, and a extra cumbersome preauthorization course of.
Constructing robust relationships with space hospital networks and doctor teams can drive admissions to a SNF’s location, which might help counterbalance a few of MA’s challenges.
SNFs ought to join with the MA plans of their market to assessment reimbursement charges. Some plans haven’t elevated supplier charges lately, which presents alternatives for SNFs to proactively attain out to barter increased charges. SNFs which are ready to indicate optimistic high quality outcomes, together with decreased hospital readmissions and strong CMS 5–star rankings, are extra possible to achieve success with these conversations.
The transfer to the Affected person-Pushed Cost Mannequin (PDPM) for Medicaid
In October 2019, SNFs transitioned from the volume-based RUG-IV reimbursement mannequin to the Affected person-Pushed Cost Mannequin for his or her Medicare reimbursement. Most SNFs made the shift easily, and by early 2020, have been well-versed within the new cost mannequin. Now, nearly all of states are shifting to PDPM for Medicaid by the tip of 2025, and this transition might show extra advanced. Knowledge means that the case combine index beneath Medicaid PDPM is decrease than it was beneath RUG-IV.
Many states are phasing in Medicaid PDPM to offer organizations time to totally perceive how one can full the brand new mannequin’s minimal knowledge set and assess the associated affect to their Medicaid reimbursement. This additionally provides the state Medicaid packages time to regulate their calculations and reimbursement methodology, if wanted. SNFs that haven’t but adopted the Medicaid PDPM would profit from connecting with friends in different states, who might supply classes discovered and finest practices to ease the shift.
Larger scrutiny for Payroll-Based mostly Journal (PBJ) reporting
Whereas there’s been enchancment, SNFs proceed to wrestle with staffing shortages. This coupled with elevated scrutiny of Payroll-Based mostly Journal (PBJ) submissions, implies that SNFs ought to be ramping up their PBJ accuracy and reporting efforts.
PBJ submissions have an effect on a company’s star score. When a SNF misses the deadline or the info is considerably inaccurate, it may end up in a 1-star score for staffing, which reduces the group’s total 5-star score. This could negatively affect managed care contracting, referral supply relationships, and Medicaid reimbursement for these packages that tie cost to star rankings.
Staying vigilant to reporting deadlines is important. Many organizations miss the PBJ submitting date or ship inaccurate staffing knowledge as a result of they lack an applicable inside course of. Having multiple individual concerned within the PBJ submission, establishing calendar reminders, and using a PBJ targeted software program are comparatively simple methods to keep away from lacking the deadline. Reviewing PBJ studies nicely upfront of the due date can be clever to permit ample time to verify knowledge accuracy and make the suitable changes.
Diversified income streams
As margins tighten, SNFs are starting to discover further income alternatives, resembling short-term rehabilitation amenities, ventilator items, dialysis providers, and reminiscence care areas to listing a number of.
Earlier than pursuing a brand new service, a SNF should first perceive the market, whether or not there are underserved wants, and who the rivals may be. A company can collect this info from discussions with hospital referral sources in addition to contemplating a market examine to know demographic knowledge together with hospital DRGs and discharge knowledge.
The group also needs to suppose via operational logistics. What medical talent set or capabilities could be required? Are there particular certifications, bodily area necessities, or tools wants? How would the census and payor-mix be affected?
Potential reimbursement ought to be a consideration as nicely. Is there increased reimbursement via Medicare? Is there further reimbursement via a state Medicaid program, resembling for ventilator providers, reminiscence care or behavioral care?
Accumulating and analyzing this knowledge could appear daunting. That is the place a third-party may very well be helpful, gathering and decoding info to assist make an knowledgeable determination.
Institutional Particular Wants Plan (I-SNP) participation
I-SNPs current one other income stream alternative, emphasizing high quality, with the purpose of conserving people wholesome and minimizing pointless hospital stays.
An I-SNP usually gives a nurse practitioner enhanced expertise and entry to finest observe medical pathways, which might strengthen a company’s medical operations. Suppliers that take part in an I-SNP could also be eligible to obtain bonus funds in the event that they obtain designated high quality benchmarks.
Residents profit from I-SNP participation as a result of these plans are designed for the nursing residence business. Whereas a typical managed care plan might supply health club memberships or different perks designed for energetic seniors nonetheless residing at residence, an I-SNP might supply SNF-focused advantages, resembling dental, or free barber and sweetness providers.
All SNFs ought to consider the potential for I-SNP participation. Due to the standard emphasis in these packages, they usually enhance long-stay outcomes, which might present a further benefit if the SNF is a part of a state Medicaid program that has a value-based or quality-based reimbursement part. Participation in an ISNP permits the supplier to share within the monetary rewards for reaching strong medical outcomes vs the upside solely going to the MA group.
A strategic strategy is critical
SNFs are dealing with a interval of nice change, pushed by rising cost fashions, value pressures, and rising calls for for providers. This atmosphere requires clear priorities and a strategic plan that connects day-to-day efforts to long-term objectives. When steady give attention to high quality enchancment is foundational to the plan, SNFs can place themselves to adapt, compete, and thrive each now and within the years forward.
Picture: baona, Getty Photos
Denise Leonard is a Associate and CPA at Plante Moran, based mostly in Cleveland, Ohio. With over 25 years of expertise within the healthcare business, she makes a speciality of helping post-acute healthcare organizations — together with expert nursing amenities, ICF/IIDs, hospital-based SNFs, persevering with care retirement communities, and residential well being and hospice suppliers — to navigate the evolving panorama of healthcare reimbursement. Denise’s experience lies in optimizing income cycle processes and growing strategic options that place organizations for achievement. Denise obtained her B.A. in accounting from the College of Akron. She is a member of the American Institute of CPAs (AICPA) and serves on the advisory board of Welcome Home, a company devoted to supporting people with developmental disabilities.
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