This presentation, using case examples, will focus on two major issues facing skilled nursing facility care: the risks and opportunities created by the combination of the current Resource Utilization Groups (RUGS) reimbursement system and the federal government’s increasing use of “Big Data” to identify potential outliers using a set of metrics; and the changes involved with the soon-to-be-implemented Patient Driven Payment Model (PDPM).
Explain the concepts of medical necessity, false claims and worthless care in relation to the quality of care in the skilled nursing facility setting, and how to apply these concepts
Describe the processes The Centers for Medicare & Medicaid Services (CMS) and other governmental entities use to evaluate medical necessity, potentially false claims and potentially worthless care in post-acute care
Discuss how post-acute long-term care providers and medical directors may be asked to participate productively in these processes to provide clinical insight and interpretation to both resolve concerns and proactively minimize risk going forward
Define the soon-to-be-implemented Patient Driven Payment Model (PDPM) and improve participants’ readiness to respond to this new reimbursement system for skilled care in skilled nursing facilities