What SLPs Need to Know About the New Medicare SNF Payment Model
Know the Facts!
On October 1, 2019, skilled nursing facilities (SNFs) implemented the Patient Driven Payment Model (PDPM) for Medicare reimbursement. PDPM bases payment for patients with speech-language pathology needs on their clinical characteristics. Here’s what speech-language pathologists (SLPs) need to know.
PDPM Does Not Dictate Staffing Changes
Under the previous payment model (Resource Utilization Groups, or RUG IV), payment was driven by the number of therapy minutes provided. Some SNFs manipulated treatment time to maximize reimbursement. SNFs that provided excess therapy may have struggled to manage staffing after the transition to PDPM because they inappropriately inflated their staffing needs.
While payment reductions have been imposed since the implementation of PDPM, these were implemented because payment to SNFs significantly exceeded the cost of delivering care to patients. In other words, PDPM did not limit or eliminate payment for speech-language pathology services, and assertions to the contrary are inaccurate. As a result, some of the layoffs or reductions in hours experienced by SLPs working in SNFs were a result of administrative choices, not Medicare requirements.
SNFs that planned for the transition to PDPM, appropriately assessed the role of SLPs, and implemented appropriate therapy service delivery methods have been able to maintain appropriate staffing and leverage the expertise of SLPs.
Because PDPM pays SNFs based on individual patient characteristics, not therapy minutes, accurate, comprehensive coding ensures SNFs are paid appropriately for the services they provide to patients. SLPs play a critical role in identifying patients who would benefit from skilled services for speech, voice, swallowing, language, and/or cognitive disorders. Medicare data about the conditions that SLPs often treat shows room for improvement in SNF coding on claims and the minimum data set (MDS).
Patient Needs—Not Administrative Mandates—Drive Payment
PDPM pays based on the clinical characteristics of patients, such as cognitive impairments, the presence of a swallowing disorder, or the need for a mechanically altered diet. While the previous system incentivized some SNFs to provide maximum treatment time, even when it wasn’t clinically indicated, under PDPM, some SNFs now mandate providing as little therapy as possible to maximize profit.
ASHA members report that certain SNF employers limit patient access to speech-language pathology services under PDPM and justify these limitations based on “Medicare requirements.” But employers who indicate that Medicare does not pay for speech-language pathology for a particular diagnosis are not being transparent about their rationale. It is important for SLPs to know that these mandates are not Medicare requirements—they are set by the SNF administration or contract therapy company. Medicare does not limit evaluations or treatment session amounts, frequencies, or durations. If an administrator takes action to limit any of these variables, SLPs can reinforce the ethical and legal obligation to provide therapy based on the skilled, clinical needs of the patient.
Medicare does not dictate how scores for screening tools included in the MDS—such as the Brief Interview for Mental Status (BIMS)—are used in making care decisions. Medicare also does not use artificial cutoffs in MDS coding for coverage and payment and expects that SNFs provide all medically necessary therapy services. As a screening tool, the BIMS is one way to help identify a patient’s needs. But it does not stand alone. Screening results are considered in the full context of the patient’s medical record and evaluation by the SNF’s multidisciplinary care team.
PDPM Does Not Dictate Productivity Requirements
Productivity standards are an industry-developed mechanism to maintain profitability and manage staff. They are not a payment policy.
ASHA opposes productivity standards that compromise quality patient care and ethical service delivery. Standards do not typically include all activities required for patient care and do not support realistic practice. This undervalues the importance of strong documentation and high-quality care for patients. These important clinical and administrative tasks protect SNFs from negative post-payment audit findings.
ASHA has developed productivity resources for our members to help them advocate for improvements to these standards with their employers.
Medicare Has Not Established Minimum Requirements for Group or Concurrent Therapy Sessions
Under PDPM, group and concurrent therapy are restricted to 25% of a patient’s total episode of care, per therapy discipline. Group and concurrent therapy should always be clinically appropriate for the patient and part of an individualized plan of care. Administrative mandates to provide a certain percentage (e.g., 10%) of group and/or concurrent therapy for every patient, regardless of need, are inappropriate, unethical, and a violation of Medicare policy. (See also: Modes of Service Delivery for Speech-Language Pathology)
Medicare Does Not Dictate Who Can Perform Therapy
Each facility makes determinations on how to use therapy clinicians in compliance with state licensing laws. If an administrator states that Medicare no longer allows you to perform certain types of services, it’s not accurate. It is likely a facility-based decision, not a Medicare mandate. For example, Medicare does not dictate that cognition or swallowing services can only be provided by occupational therapists or SLPs.
Medicare Does Not Require Mandatory Evaluations for Every Patient
A brief assessment or screening can help an SLP determine if a full evaluation is warranted. The SLP’s clinical judgment and the needs of the patient remain paramount in the decision-making process. Administrative policies that mandate an evaluation and at least one treatment are inappropriate, unethical, and fraudulent when not clinically necessary.
Medicare Has Not Changed the Definition of Skill That Triggers Coverage in SNFs
Care in SNFs is covered under Medicare Part A if the following four factors are met:
- The patient requires skilled nursing services or skilled rehabilitation services (i.e., services that must be performed by or under the supervision of professional or technical personnel); are ordered by a physician and the services are rendered for a condition the patient received inpatient hospital services for or for a condition that arose while receiving care in a SNF;
- The patient requires these skilled services daily;
- As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; and
- The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury (i.e., they are consistent with the nature and severity of the individual’s illness or injury, the individual’s medical needs, and accepted standards of medical practice). The services must also be reasonable in terms of duration and quantity.
See: Medicare Benefit Policy Manual [PDF]
Medicare Has Not Replaced Clinical Judgment and Professional Standards of Practice With SNF-Developed Administrative Mandates
Clinicians can advocate for appropriate clinical services with their employer. The need for clinical judgment and corporate compliance reporting remains the SLP’s professional obligation. Administrative mandates that run counter to the clinical needs of the patient are inappropriate, unethical, and considered Medicare fraud.
ASHA Resources
- Medicare Skilled Nursing Facility Prospective Payment System
- Demonstrating the Value of Speech-Language Pathology Services in the Patient Driven Payment Model (PDPM)
- SLPs in Health Care: Communicating With Administrators
CMS Resources
