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  • CMS Proposes Major Change in SNF Payment System

    The payment world could change dramatically for skilled nursing facilities (SNFs) as early as October of next year if the US Centers for Medicare and Medicaid Services (CMS) follows through on a proposed rule.

    On April 27, CMS unveiled its proposed SNF rule for 2019, which includes plans to replace the existing SNF case-mix methodology, known as Resource Utilization Groups Version IV (RUG-IV) with an entirely new system dubbed the Patient-Driven Payment Model (PDPM). CMS believes the new model will save money and improve care by reducing administrative burden and tying payment to patient conditions rather than services provided. The new system would go into effect on October 1, 2019.

    Under the PDPM, payments would be based on a resident's classification among 5 components—physical therapy, occupational therapy, speech-language pathology, nursing, and "non-therapy ancillary services," a category mostly related to drugs and medical supplies. Payment would be calculated by multiplying the case-mix index for the resident's group with each component, first by a base payment rate and then by days of service received. The payment calculations for each component would then be added together to create a resident's total per diem rate.

    The big picture: CMS believes the new system would shift payment away from the focus on volume-based services associated with RUG-IV and toward "incentives to treat the whole patient." That shift also would come with "significantly" reduced administrative burdens, according to a CMS fact sheet on the proposed rule.

    The new model is itself an overhaul of sorts of a case-mix methodology system CMS floated last year. That model, known as the Resident Classification System (RCS-I), met with heavy criticism from a wide range of stakeholders, including APTA. The association argued that the plan was based on an inadequate set of patient characteristics and a poor understanding of the impact of comorbidities, and likely would reduce therapy for patients most in need. Initial analysis of the PDPM reveals that CMS may have listened to that criticism, creating a system that it says "puts the unique care needs of the patient first."

    To ensure that SNFs are delivering the kind of care envisioned, CMS would add 2 new therapy reporting requirements to the discharge assessment—the first aimed at documenting therapy minutes and each therapy mode used, and a second focused on days for each discipline and mode of therapy. CMS hopes that monitoring both minutes and days will allow it to get a better handle on the daily intensity of services provided—something that's difficult to do under the current RUG system. In addition, the new system would limit concurrent and group therapy to 25% for each discipline.

    Other elements of the proposed SNF rule:

    • Overall payments to SNFs would increase by 2.4%, or $850 million.
    • The reporting window for the public display of SNF outcome measures would be expanded from 1 to 2 years, a change that CMS believes will require more SNFs to participate and is in line with current requirements for inpatient rehab facilities and long-term care hospitals.
    • Beginning as early as 2020, CMS would begin publicly displaying data related to changes in self-care and mobility during SNF care and at discharge.
    • CMS would add a cost-benefit analysis as an additional factor when considering potential outcome measures to remove from its list of requirements.

    And while no actual changes are being proposed, CMS is using the release of the proposed rule to remind SNFs that beginning in October 2018, SNFs could receive increased or reduced payments depending on their performance on the SNF value-based purchasing program's readmission measure. The measure, based on all-cause 30-day hospital readmissions, doesn't require SNFs to report additional information, since CMS will use existing claims information to make the assessment.

    APTA regulatory affairs staff are reviewing the rule and will draft comments for submission before the deadline of June 26, 2018.


    • At an initial glance of this proposal, it appears that it would limit rehab services to the most needed patients, also appears to be a disaster to the profession itself. Limiting ,declining or reducing an service to the needy , especially in healthcare should not be the criteria to save money.

      Posted by Boby Thomas on 4/30/2018 9:05 PM

    • Please modify it further for patient to receive the rehab care they deserve better. Tgx

      Posted by Rajeev Tiwari on 5/1/2018 1:11 PM

    • Any kind of regulations on healthcare should be patient oriented In order to improve their health and quality-of-life; But the proposed changes by the CMS is sorely money based and it will adversely affect the patient’s health and quality-of-life

      Posted by Joseph J Jacob on 5/1/2018 10:10 PM

    • If I'm reading this correctly, all this is going to do is push facilities to keep patients longer in order to get paid more. This will reduce available beds, shutting more people out of these facilities. If group therapy is limited (which is not entirely bad), this will likely cause a higher employee turnover/burnout rate, and/or force more companies to hire more staffing to provide the increased amount of one on one care. Do they actually have people who work in these facilities to help craft these things?

      Posted by Cody Thompson on 5/2/2018 9:59 AM

    • Can therapy take any more hits. Therapist already need to see 10 to 13 patients a day to make a very hard 8 hours. How is it that the companies and upper management still come out ahead. Shouldn't the people who give away time and break their backs to help patients recover still be able to make a living. The companies just learn how to make money and don't worry about the physical and financial deficits of the people doing the work. I wish someone would cut out the middle man and make sure patients get what they need along with their therapists.

      Posted by Heather Sharkey on 5/2/2018 9:45 PM

    • This shows the importance of therapists being ethical in their approach to patient treatments. We are physical therapists with expertise in musculoskeletal problems as related to diseases and movement. That should be the driving force when we evaluate and assess the patients and establish their treatments/plan of care. That is also why it is important that PTA's and PT's work together as a team with the PTA remembering that the PT establishes the plan of care and direction of patient treatment. The PT therefore has the ethical responsibility to ensure they have completed a thorough and comprehensive treatment plan for the PTA to execute/follow. If we do not work together PT's and PTA's in an ethical ,responsible manner reflecting the professional skills we bring to our patients from our training we may no longer have much say as to the reimbursement and direction as professionals, healthcare takes, so that we can efficiently and effectively deliver care to the patients . Sadly because standards vary so greatly from State to State, the ethical States suffer for the less ethical States.

      Posted by Anne Kenny on 5/6/2018 9:20 AM

    • absolute disaster to the rehab profession. The PDPM aims to save money by compromising rehab care.

      Posted by vishal on 5/21/2018 1:53 PM

    • Sounds like we are just trading high session minutes to high number of days now. Not sure how this is better. Instead of 75 minutes in 5/6 days a week days... now 30 minutes for x amount of days in a row. Bad for patient they need some recovery days. Much less the staffing issues that will be worse. Maybe I miss understand. Hope so.

      Posted by Concerned on 8/14/2018 7:31 PM

    • Agree with comments by Ms. Sharkey & Ms. Kenny. I am a long time professional who has worked in the industry closely with rehab and reimbursement for a long time. Before the Rehab and reimbursement merged, so as to say, and became so calculative, there was a time and still is in a few very small SNF's. The Therapist are hired directly by the SNF (full time or part time), they are accountable directly to the facility, so they did not have two bosses, (their primary Rehab company and the facility they work for) The Therapist have the freedom to evaluate the resident and plan the treatment minutes based on their professional expertise and resident needs. Rehab RUG guide them not dictate them. Unlike today when RUG requirements, productivity, and other guidelines of the Rehab company sets the tone for the evaluation and treatment. Sounds harsh but is the reality, the outcome of which is evidenced in many study reports. OIG Report of 2010. " Even though SNFs significantly increased their billing for these higher paying RUGs, beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008".This has neither benefitted the therapist nor the resident, only the middle man the Rehab company. CMS tried various ways to discourage this behavior but the problem still prevails. will the new payer method change something ?? It time to go back to the basics. Professionals have the responsibility to stand up to the standards of the profession and practice.

      Posted by Susan Patel on 8/15/2018 1:39 PM

    • The question arises when it's based on diagnosis for reimbursement faculties will discriminate which h population they want based on the higher reimbursement for those diagnosis and shorter stays means inconsistency for facilities to provide consistent hours for workers and a harder time differentiating minutes to use under the new system. The rural area facilities will go bankrupt under this system so the question is the government going to subsidise these facilities to keep them open. Local taxes increase to promote these facilities and cost go up with amount of govt subsidies needed

      Posted by mark j huestis on 9/4/2018 9:59 PM

    • Its about time cms is realizing the fiscal responsibility concerning reimbursement with skilled pets. No one requires 720 min ultra rug. And all disciplines have for years been challenged with the ethical and fraudulent billing on these pts. What a relief for clinical providers that boundaries are finally set, due to the greed and productivity requirements of providers and ltc. I say stop the insanity of 100 days and ultra levels, even though it effects me and my colleagues in the pocket. Thank God it's about time.

      Posted by Tom weber on 9/11/2018 5:13 PM

    • I disagree with above post. The Rug based system works when the therapist gets to make the decision about how much therapy should be given. The problem is everyone has there hand in the pot. Why are we paying middle management to make decisions about the patients we see. Take back the control and do the right thing. Drain the swamp - Get rid of middle management's ability to make decisions about minutes and patients POC. Give back the control to the therapists and the patients.

      Posted by Jonathen davis on 9/19/2018 9:02 AM

    • So does this effect the job security of PTAs and OTAs?

      Posted by Melvin Abraham on 9/25/2018 11:32 PM

    • If we are going to be a complete doctoring profession why be treated as laborers(watched and billed by labor time) . Why not a Surgeon's and physicians time work be billed as minutes as well like us laborers to cut cost in whole. I agree the patient derived payment system should eliminate all upper team members first ( Rehab director , regional rehab director and zone managers ,division managers . the cut should begin from the top ) Before (In the SNF set up) PT's were managers, then OT's were managers now every SNF has placed a ST as manager as there caseload is always slim and they have almost nothing to do to bring more money. They tell other disciplines to bump up the minutes to keep their jobs and the upper management happy as well Lets hope changes are for better

      Posted by PT on 10/3/2018 5:53 PM

    • Amen to Jonathan Davis. Allow therapists to make the decision. Also inform patients and family members that more therapy doesn’t always result in significant improvement. High time physicians share information regarding prognosis for improvement in chronic conditions and what to realistically expect in a skilled nursing facility. An informed patient/ family member makes for a more satisfied customer.

      Posted by Enid Flaisher on 10/3/2018 10:32 PM

    • I hear the reimbursment is reduced every 3 days in a SNF- to cut down on facilitie's attempts to prolong length of stay. The big losers will surely be the patients. I think these things should be discussed for the entire nation to hear about- they have no idea what's coming.

      Posted by Nina on 10/23/2018 8:57 PM

    • CMS have already done their homework. These services could be done at home and save taxpayers money.

      Posted by Nurse on 11/10/2018 9:24 PM

    • This does nothing to solve the “Push” for revenue that contract companies implement. I have worked in therapy for over 20 years and the switch from facility employed therapy staff to contract therapy has caused therapy staff to either get on board with whatever makes the contract company more money or be fired. 97% productivity requirement for therapy staff encourages fraudulent billing to protect therapists job. Therapists can’t be ethical because it costs the contract company money.

      Posted by Tammy on 11/18/2018 11:35 AM

    • As a therapist who works part time in snf's I hope this bill kills all these contract therapy companies. They are ripping off the government dictating who gets seen and how many minutes they are seen based only on profits. They now are making some of my peers have 98 percent productivity and expect them to get their paper work done. This is impossible to do ethically unless you do ppw at home. I think any change is a good change at this point.

      Posted by nicholas smith on 11/19/2018 2:19 PM

    • Maybe it's time for a Healthcare Labor Union. We need the people to come together to stop this abuse of the Therapist and the Patients.

      Posted by Jerry on 12/12/2018 9:35 PM

    • I don’t know about each of you, but my facility is worried it might have to cut down the therapy staff in order to adjust these changes. What are y’alls thoughts? I’m worried I might lose my job over this overhaul that the APTA apparently supports.

      Posted by Kyle on 12/21/2018 1:38 PM

    • I see a lot of PTs posting here about the "disaster to the profession" this will be, "not giving patients the care they deserve", etc etc. Stand back and consider this: MEDICARE IS NOT GOING TO SURVIVE PAST 2030 AT CURRENT USAGE RATES. So what do YOU propose? Giving current users benefits at current rates , effectively stealing from younger people who are contrubuting now but will not have the same access to services under Medicare past 2030, should not be an option. Methinks there is no small amount of self-serving rhetoric involved here. Anyone who has worked in an ECF and has an ounce of objectivity, knows that not all the therapy that goes on there is really needed. In fact, there is enormou WASTE there, even with Part A pts, not to mention Part Bs. But hey, this is the USA, where current voters and the politicians who demagogue them can defraud young non-voters or the yet-to-be-born (that is, if they even allow them to be born). Just like deToqueville and others said, as soon a the citizens are no longer virtuous, the American system of representative democracy will no longer work; or, just like Plato wrote some 2500 years ago, democracy eventually leads to tyranny. This thread is just another reminder of that.

      Posted by larry brown on 12/25/2018 12:05 PM

    • I’ve been a PTA in HH and SNF settings for five years. Got tired of the BS and fraud and went back to school. I start PA school this August. Guess I dodged a bullet. I hope the DPTs and MOTs can grow a spine and stick to their principles. Without them sticking up for their profession to middle managers therapy will go the way of the chiropractor

      Posted by PTAtoPA on 1/6/2019 8:39 AM

    • What this means is the SNF industry will try to scale down how much therapy is delivered to maximize profit. CMS wants to pay less, businesses want to make a profit and therapist are not going to take a cut in pay...the beneficiaries are the ones who suffer. I've worked as a staff and manager in rehab, OP, HH, and SNF...i've seen the degradation of healthcare over the past 20 years. Until CMS puts an end to the fraud and or starts doing take backs on the companies and therapist that commit fraud, this will be an ongoing cycle. The end results are those needing the care will not get what they truly need to get the results they could.

      Posted by MH on 1/21/2019 3:40 PM

    • The focus must remain on the patient and meeting them where they are. We must work to continue to deliver high quality and cost effective health care by use of our skilled interventions. Continue to use normative data to demonstrate progress and help each patient to navigate their own recovery. This is why we went into the profession and why we will always be needed to help in the provision of healthcare. Focus on the patient.

      Posted by John McClure on 1/30/2019 9:50 PM

    • Can anyone tell me what ithis all means for the PTAS and COTA's.???. I work for a rehab company that is inhouse .. would this change in rugs ,mean that I will no longer have a job !!😫

      Posted by PTA on 2/6/2019 6:53 PM

    • @ "PTA" - Thanks for the question! While the new SNF payment model does away with the RUG-IV system, the payment model in no way diminishes or devalues the clinical importance of therapy. The goal of the new SNF model, as well as the new home health payment model, is to provide appropriate payment based on identified resource use of different patient groups; it is not designed to encourage, discourage, value, devalue, or promote one type of skilled care over another. Regardless of the changing payment methodology – it continues to be important for PTs and PTAs to demonstrate the value of the impact they have on patient care and restoring patient function. PTs and PTAs in SNF and home health settings must continue to show how they provide successful person-centered care with optimal outcomes. PTs and PTAs working in these settings should be conversant in and prepared for the opportunities and challenges the implementation of the SNF PDPM and Home Health PDGM provides to the profession. We encourage you to check out APTA's SNF and home health payment models webpage (http://www.apta.org/Payment/Medicare/NewPaymentModels/ ) for more information on the policies related to the new payment models. APTA will continue to share more resources on this webpage related to the new models in the coming weeks and months.

      Posted by APTA Staff on 2/7/2019 9:09 AM

    • The staffing who chose to worry about patient and their care...kudos to you... The rest I don't know what you are all complaining about...? My man against his will was put in a rehab 2.5 years ago, and has not received any rehab...most stay only 27 days... I had him walking and talking at home...now he lays there...and you people are worried about cut backs...your not doing anything productive then so why pretend you are...? Jobs are based on the performance factor.. Not what you can get away with and get paid for...I rarely see any therapy going on anywhere... I am being negative I know...but damn it … there are some really good therapists...I do know that! Has nobody wondered why so many are in there to begin with? Many are being held against their will, hidden from families, drugged to not remember they had family and find themselves there...families come and they want to go home...oops family is upsetting them...family is not allowed to see them again...and you pray that the therapy is doing their job...and those people get better and are able to walk out...if they don't drug them so they cannot function... Look in their chart who admitted them...? A guardian...then they probably want to go home...illegal profitable guardianships stealing estates, corruption with judges and lawyers and guardians...is why they are there...hidden from families...1.5 million admitted and in guardianships... MY MAN BEING ONE OF THEM... all I see is the billing and hours to work on what billing preference...your physical therapist...do you not take pride in your ability to make someone walk again from your care and concern? Oh sorry that is lacking and your pay is all that is important... I apologize for this bashing on you all...but a mans life is at stake and to think in 2.5 years in a rehab he would be able to then walk out... Who do you go to when that happens and he is not any better? They do not want him to walk out and none of the people in SNF care if they do walk again...really! Sad… how about going independent and work with them from home where they are loved and cared for and will help you improve their conditions... MY EXPERIENCE WITH THERAPY... SORRY AND HOPE YOU ALL FIND YOUR BILLING WAYS TO BE SUITABLE FOR YOU

      Posted by Carlena on 3/22/2019 7:27 AM

    • I wish some of you would quit worrying about your job and learn how to spell. Please learn the difference between affect and effect. Bottom line is if your doing your job correctly you should have nothing to worry about. The only change is going to be the people.

      Posted by Eric reynolds on 4/2/2019 3:07 PM

    • How does this affect coding?

      Posted by Mary Wilson on 6/13/2019 9:38 AM

    • jerry, the "Healthcare Labor Union" for PTs is the APTA. are you a member??? i am!!!

      Posted by eric on 8/16/2019 8:47 PM

    • PDPM is here and LAYOFFS have started. Hey Eric Reynold hope you dont work in SNF you will be laid off first.

      Posted by B on 9/17/2019 5:58 PM

    • I have been a COTA for 15 years and never seen anything like this. I work home health and SNF’s and my caseload dropped by 1/2 in 1week and they SNF I work in don’t need me because they are laying people off or the full time therapist are not getting there hours. This is very scary as many of you I having family to support . This isn’t about spelling or how good you are as therapist . Remember in this field you are always replaceable. It’s about money !!! . I have been looking for jobs in my area and all I see is PRN . Seriously I don’t know what to think . Is this the end of our careers in therapy or this something that will fade out?

      Posted by Marie bailey on 10/23/2019 1:34 AM

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