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Georgia State Office of Rural Health & HomeTown Health, LLCWelcome you to the:
This project is supported by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) grant number 16062G.
2016-2017 Rural Swing Bed Management (RSBM) Training Program
Use of Swing Beds in PPS Hospitals:
Focus on Medicare
Best Practices for Compliance & Efficiency
Webinar Etiquette
• All attendees are in “Listen Only” mode
• Questions or comments?- Open “Questions” pane in
dashboard- Type in comments or questions- Comments will be monitored
through out webinar. - Questions will be addressed at end of the webinar.
Webinar Resources
• This webinar will be recorded and emailed to you to share with others on your team.
• Handouts are available for download in the Handouts pane, and were emailed to registered attendees this morning. Please let us know if you did not receive the email.
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Continuing Education Unit Conditions
As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEUs/1 credit hour for this program today.
In order to obtain these CEUs, you must: • Attend webinar/view recording in its entirety
within 30 days• Pass online quiz with 80% or better.• Complete webinar evaluation.
Continuing Education Unit Conditions
Following this webinar, all attendees who have viewed the
recording in its entirety will receive an email with an HTHU.net
link to the optional webinar recording, online quiz, online evaluation and online certificate of completion.
Anyone that misses the webinar or attended less than 90% of the live webinar will receive an email with the webinar
recording and steps to obtain CEUs.
New to HTHU? Register for Free, Make sure to select your
hospital from the Organization Dropdown
Returning Students? Login
Continuing Education Unit Conditions
Are you attending in a group? Please add other attendees’ first name,
last name and email address in the Questions pane.
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Agenda
Welcome & Introduction Desi Barrett, Webinar Program Manager
Use of Swing Beds in PPS Hospitals:Focus on Medicare Presentation
Kerry DunningRSMB Program Trainer Kerry Dunning, LLC
Next StepsDashboard & Calendar
Desi Barrett, Webinar Program Manager
Kerry Dunning, MHA, MSH, CPAR, RAC-CT
Kerry Dunning LLC
• Ms. Dunning has 20 years in health care consulting and over 30 years in the industry. • She specializes in the post-acute market working with hospital based skilled nursing
and swing bed programs, critical access hospitals, freestanding skilled facilities, inpatient/outpatient rehab programs, inner city teaching hospitals and rural health care systems.
• Ms. Dunning worked for HCA and HealthTrust hospitals in administrative roles; Horizon Rehabilitation and ServiceMaster Rehabilitation as a Sr. Vice President and Chief Operating Officer; with GPS Healthcare as the Chief Senior Services Officer; and has spent more than 20 years as an independent consultant.
• In addition to serving as an Adjunct Instructor in the College of Health at the University of North Florida, Ms. Dunning regularly leads workshops and webinars regarding Medicare, skilled nursing (including MDS), swing bed programming, and reimbursement cycle improvement. She also works on international health care projects and research.
• Her favorite job is on-site helping facilities take better care of patients.
Contact Kerry at: 904-923-7229 or [email protected]
Kerry Dunning, MHA, MSH, CPAR, RAC-CTKerry Dunning LLC
November 2016
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� Description: This webinar will review the key elements required by Medicare for a swing bed program including Medicare Intent, Conditions of Participation, CMS and Federal Regulations, required Medicare documents, Medical Necessity and documenting requirements, and an introduction to the RSBM Dashboard.
� Objectives:1. Review the Conditions of Participation and address overlooked
requirements2. Know the 5 required Medicare paperwork documents and other
key regulations3. Learn the CMS definition of medical necessity documentation4. Begin to collect and track Dashboard data necessary for future
Swing Bed business
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� Opportunity to ask questions
� If you are not sure you are doing it correctly AND you do not want to say so publicly . . . Email listed at the end
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� The education offered by Kerry Dunning, LLC in this program is compensated by the Georgia Department of Community Health (DCH) State Office of Rural Health (SORH) under grant number 16062G.
� Lisa Carhuff, Director of Hospital Services, Georgia State Office of Rural health obtained the grant
� HomeTown Health is managing the grant for SORH
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� Therapy Patient Admissions ranged from 100% to less than 10% ◦ Nearly 60% said therapy admissions account for more than 80% of
the swing bed admissions� Of the “first” diagnoses listed by each participating site –
even though they were primarily therapy patients – over 70% named ◦ CHF◦ COPD◦ Pneumonia
� Average Length of Stay (ALOS) ranged from 2.9 days to two weeks
� Admissions from your own hospitals started only 1% to 88%
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� Access to health care is important, and as the gap widens between urban and rural, SWBs reduce the chances of closure
� Rural Hospitals treat some of the sickest patients◦ Helps avoid rehospitalizations
� The greatest strength is the breadth of primary care services to care for more patients locally across the care continuum◦ Looking at creative ways to use more swing beds as acute census
declines
� Important to the community◦ Time sensitive stabilization (disproportionate % of trauma deaths
occur in rural areas)◦ Community jobs
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� Payment for bed utilization equates to more than an empty bed◦ Assists with DRG management
� Excess capacity in staffing most often allows you to provide this new service without increasing staff cost
� Assists with ancillary staffing productivity� Avoid transfer rules
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� Skilled level care to identify patient needs and address safety issues
� More time for family education� Increased patient/family
satisfaction � Return from larger hospital to
home area
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� Return of residents to area nursing homes when possible◦ Nursing Homes are frequently not staffed or equipped to offer
comprehensive skilled care – patient’s acuity may be too high for a community-based SNF
� Home Health is paid a specific amount per 60 days regardless of needs, hence do not object to a few extra days in the hospital to decrease acuity and increase stabilization ◦ Home Health are paid under PPS by discharge
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� Hospital systems are looking for “partners” to help manage the post-acute needs
� CJR and other Bundling directives◦ Time to be working with referring hospitals◦ Insurance companies looking for skilled nursing option
� Do you know what is going on with your area SNFS?◦ 5-Star rating?◦ Staffing ratios?◦ Quality Measures?
� Regardless, must be ready to provide all services
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� Types of Data◦ ALOS◦ ADC◦ Cost per episode◦ Outcomes◦ Return to hospital within 30 days (from home or home health)
� Care Coordination and Quality Improvement◦ Looking for “handoffs” between hospital and post-acute
settings◦ Patient satisfaction◦ Quality Measures
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� Train to CMS rules◦ Medical Necessity documentation◦ Medicare required “paperwork”◦ Understanding Medicare intent
� Most Common Use of Swing Beds:◦ Need was for physical and occupational therapy for orthopedic
patients◦ Patients needing strengthening following their hospital stay◦ Patients requiring wound care◦ Patients getting intravenous antibiotics
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� SOM Appendix T� §482.58 Special Requirements for Hospital Providers of Long-Term Care Services
(“Swing-Beds”)� The facility is substantially in compliance with the following skilled nursing facility
requirements contained in subpart B of part 483 of this chapter.◦ (1) Resident rights (§483.10(b)(3) through (b)(6), (d), (e), (h), (i), (j)(1)(vii) and (viii), (1), and (m) of
this chapter).◦ (2) Admission, transfer, and discharge rights (§483.12(a) of this chapter).◦ (3) Resident behavior and facility practices (§483.13 of this chapter).◦ (4) Patient activities (§483.15(f) of this chapter), except that the services may be directed either by a
qualified professional meeting the requirements of §483.15(f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy.
◦ (5) Social services (§483.15(g) of this chapter).◦ (6) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), (k), and
(l) of this chapter, except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter).
◦ (7) Specialized rehabilitative services (§483.45 of this chapter).◦ (8) Dental services (§483.55 of this chapter).
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� The same rules apply to the Swing bed patient as they do for the Skilled Nursing facility.
� Enrolled in Medicare Part A� Benefit days available to use� Within 30 days of discharge from the hospital� Requires 3 midnight acute stay (no OBS)� Need for skilled care on a daily basis provided by or
under the direct supervision of skilled nursing or rehabilitation professionals◦ Nursing x 7 days/week and/or◦ Physical Therapy x 5 or more days/week
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� The provisions of the MSP may be found at 42 U.S.C. §1395y (b) and mandatory Insurance Reporting requirements were enacted by Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (“MMSEA”)
� For Medicare to render payment for skilled services provided to a beneficiary during a Medicare Part A Stay it must be completed
� Completed at Registration/Admissions◦ Must have a new MSP for a swing bed stay
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� Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services= Medical Necessity◦ The certification /recertification of the treatment plan is the technical
requirement for payment, not the referral. ◦ If not completed, it is an automatic denial on Medical Review. (Rev.
1, 09-11-02; SNF Manual Chapter 2, Section 220 - Coverage of Services)
� As a “practical matter” the services can only be provided on an inpatient basis in a Swing Bed or Skilled Nursing Facility ◦ Patients are admitted to a Swing Bed Program if they are not at an
acute level of care any longer (i.e. medically stable and no longer require telemetry)
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� “Care as determined by physician must be medically necessary and certified/recertified by a physician”
� Certification: Must be signed and dated on admission� Recertification: Must be signed and dated on or before
the14th day of skilled care and every 30 days thereafter� Physician must date the certification on the date he actually
signs it-it may be faxed◦ Certifications may be signed by physician, ARNP or PA working in
collaboration with a physician who does not have an employment relationship with the SNF
� Stamped signatures are not allowed� Handwriting must be legible
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� For an item or service to be considered medically necessary, it must be: (1) Consistent with the symptoms or diagnosis of the illness or
injury under treatment; and (2) Necessary and consistent with generally accepted
professional medical standards (i.e., not experimental); and(3) Not furnished primarily for the convenience of the patient or
the physician; and (4) Furnished at the most appropriate level that can be provided
safely and effectively to the patient.
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� Medical necessity documentation is a compliance issue for all healthcare providers
� Two troubling aspects of this issue are:◦ Medical necessity is subjective an judgments must be made◦ For Medicare and other third party payers, the judgment of
medical necessity is made after the fact
� “Insufficiently Explanatory”
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� The following consents, at a minimum, should be obtained on admission to Skilled Care.◦ Consent to Treat� Patients must give consent for treatment, verifying the patient has
been fully informed regarding the benefits and risks of any procedure or treatment. 45 CFR 164, 42 CFR, CH IV, Part 483
◦ Consent to Bill◦ Consent for Medical Records Release◦ Consent to Photograph◦ Consent for Release of Information from Social Security
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� MDS assessments are required for Medicare payment (Prospective Payment System [PPS]) purposes under Medicare Part A (described in detail in Section 2.9 In the RAI Manual).
� Acceptable ARD date� RUG Classification� New MDS – October 1 (more than Section GG changes)� Facility Final Validation Report◦ Error messages◦ Fatal errors◦ Warnings
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� Regulation: Medicare Services Manual 30.4.1.1 -General◦ (Rev. 73, Issued: 06-29-07, Effective: 07-30-99,
Implementation: 10-01-07)
� Skilled physical therapy services must meet all of the following conditions:◦ The services must be directly and specifically related to an
active written treatment plan that is based upon an initial evaluation performed by a qualified therapist after admission to the SNF and prior to the start of therapy services in the SNF that is approved by the physician after any needed consultation with the qualified therapist
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� The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable
� The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist
� The services must be reasonable and necessary for the treatment of the patient’s condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable.
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� The therapist, in conjunction with the written Plan of Care, provides therapy services to the patient. The minutes provided are kept in a “log” or on the daily treatment sheets. Those minutes are then reported to the MDS Coordinator to enter into the MDS
� The minutes provided MUST match the minutes entered into the MDS
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� Services delivered to a Medicare beneficiary are to be reduced or terminated following delivery of covered care, or thought not to be covered under §1862 (a) (1) of the Act, in order to shift liability under §1879 of the Act
� Providers must give these notices before services are delivered for which the beneficiary may be liable
� Failure to provide such notices when required means the provider will not be able to shift liability to the beneficiary
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� Deliver 2 days prior to discharge even if they agree with the termination of services◦ Applies to Medicare & Medicare Advantage/Combined to one notice
� ABN is given if the patient decides to continue with services once the decision is made
� Do not give when benefits are exhausted or reduced� Patient has right request an expedited review by the QIO;
Form CMS-10124◦ If requested deliver by close of business day they day you are
notified
� Do not routinely give notice at the time services begin unless the service is expected to last fewer than two days
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Different than theImportant Messagefrom Medicare
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� PRE-ADMISSION◦ Not extended IP stay◦ Reducing medication cost
� Medical Necessity ◦ No standing labs or unnecessary x-rays◦ RT versus Nursing staff
� MDS Management◦ Right RUG◦ Right days (i.e., not less than 5 day stays)
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� Covered Individual� Covered service or item� Ordered by a physician or qualified practitioner� Medically necessary� Provided by qualified facility or healthcare
personnel� Appropriate Documentation� Billing privileges with the Medicare Program� Proper claim, filed timely
RECOMMEND TRIPLE CHECK
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� Chapter 8, Medicare Benefit Policy Manual� Chapter 6, Medicare Claims Processing Manual� Code of Federal Regulations, www.ecfr.gov/cgi-
bin/ECFR� Social Security Laws (Titles 18 & 19)� Corporate Compliance� QAPI� HIPAA
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� Social Admits/Custodial Care are not swing bed patients� Physician did not certify or recertify � 3-Day Qualifying Stay not met� Other:◦ More than 30 Days have passed since discharge from 3 Day
Qualifying Stay◦ Benefits Exhausted◦ Benefit Period has ended
� NOMNC not given to patients� Claim submitted for a days of SNF care but documentation
does not support SNF care received� Documentation from physician states patient no longer
needs SNF care & is ready to go home
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Program Dashboard & Ongoing Communication
Online Dashboard:www.hthu.net/swingbedpps
Password Protected: pps
Ongoing Email Communication will come from HomeTown Health on a monthly basis.
Your RSBM Team
Kerry Dunning,Trainer & Program Director,Kerry Dunning, LLC
Jennie Price, Director of Business Development, HomeTown Health University
Desi Barrett, Webinar Program Manager, HomeTown Health
Kristy Thomson,COOHomeTown Health
Contact Information
Desi Barrett, Webinar Program Manager
[email protected] Thomson, COO
Jennie Price, Director of Business Development
Kerry Dunning, RSBM Program Trainer
