As you probably already know, CMS has recently extended the comment period for RCS-1 which is their proposal to dramatically shake up the prospective payment system for skilled nursing facilities.  Currently, RUG based payments under the SNF PPS are based on the amount of therapy provided to a patient regardless of the specific patient characteristics and care needs.  In RCS-1, CMS is clearly trying to move away from reimbursing SNFs based on the amount of therapy being provided.

You may be asking yourself at this point, “Why should I spend time thinking about RCS-1 when it is a long ways away from being finalized?”  A good question!  We have asked ourselves the same question as well.  However, at Therapy Specialists’, we believe it is worthwhile thinking, discussing and planning for this new model, because while it might look different in its final form, a payment system based on the patient characteristics, needs and outcomes is inevitably in our future, and with quality measures, an increasingly important part of our present success.  Therefore, in this post, we want to give you three things to discuss with your rehab provider as they prepare, along with you, for a world where the volume of therapy services provided no longer determines your reimbursement.

1. Using the Right Diagnosis

The I8000 box in the MDS will become very important and will require close communication between therapy and nursing.  The better prepared therapy EMRs plan to have an algorithm that uses objective information to help determine the most appropriate diagnosis to place in the I8000 box.  This may be based on a quick assessment that’s completed by the interdisciplinary team, within that first 48 hours, to help give the team an idea of what category the patient may fall into.  This will ensure that the team can manage resources and doesn’t have to wait for the MDS data to come in, which under the new model is not until after day 5.  Your therapy provider should then use resident needs and the CMI (Case Mix Index) to guide planning and delivery of needed therapy services ensuring that practice patterns for therapy services will not change too dramatically and patient outcomes that drive quality will not decline.  This part is very important as there is a high likelihood CMS will be closely auditing for changes in the frequency and intensity of therapy services SNFs provide under a new reimbursement model.  If there is a significant change in frequency or intensity of services provided based on the reimbursement changes in RCS-1 that are not supported by medical necessity, the facility could be at risk for post pay review for pre-RCS RUG utilization.

2.  Justification for Therapy Services

You want to make sure your therapy provider is able to provide enough training on ensuring the minutes your rehab team provides match up with the needs of the patient.  Projections show that in this new model that reimbursement will decrease the longer the patient stays in your facility.  So your therapy provider has to justify why the patient requires skilled level of care upon admission as well as throughout their stay.  They need to continue to set goals appropriately and document them clearly.  Also, make sure your therapy provider includes a statement in their documentation supplying rationale about the frequency and intensity of the therapy they provide each patient.

3. Just Like Managed Care

Aspects of the proposed RCS -1 reimbursement model are very similar to traditional managed care models.  We have a tremendous amount of experience in the managed care world where we have learned to be flexible and achieve great outcomes with limited resources.  In the managed care world, everything is based on function.  Establishing and understanding prior level of function will be extremely important.  Once you have established prior level of function, the therapist will need to set patient- centered, measurable, attainable goals for the resident’s progress with therapy.  We recommend your rehab team begin using an occupational profile prior level of function tool that will help the therapist define what the patient has to do to before discharge, and how the therapists can help them be most successful in their home environment.

Conclusion

We think there’s opportunity with this aspect of RCS-1 to look at it like everything that’s old is new again.  Accurately assessing the complexity of the patient’s condition, justifying the amount of therapy being provided, and setting measurable goals for the patient’s progress with therapy are all things rehab providers need to become better at under the new payment system.  Have you talked to your therapy provider about how they are preparing for RCS-1?  We would love to hear from you about the areas you are most concerned with in the new payment system being proposed by CMS.