THE M3 REVIEW - BEYOND PDPM - SNF VBP & QRP

There are 4 new measures to be considered in the FY 2027 SNF VBP.  Do you know what they are?  Is your IDT tracking them?

Transcript

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Welcome back to another fantastic episode of the M3 Review. Today is all about the 2027 SNF VBT. And before we jump into the details, I want to set the stage for what this program is really about. The SNF Value-based purchasing isn't just another CMS quality program. It directly affects your Medicare revenue. You can't outcode this. For fiscal year 2027, CMS has expanded the program to eight quality measures. Your performance is now evaluated across multiple areas that reflect both the quality of care you're providing and how well your residents do after discharge. During this session, this podcast today, we're going to break down each of those eight measures, talk about how CMS calculates your performance score, and explain how that translates into your incentive payment multiplier and ultimately your reimbursement. We're going to spend some time on section GG because it's so important. Your functional documentation, your discharge outcomes, and your ability to safely transition residents back to the community all play a major role in this program. One of the biggest mistakes I see facilities make is treating PDPM, VBP, and QRP as three separate programs. They actually are not, but yet again, they are. They all rely on the same documentation and assessment process, and success in one often supports success in the others. By the end of this podcast, my goal is for you to understand how they all work together, understand all the measures, and what your IDT can do every day to improve the quality outcomes while protecting your Medicare revenue. CMS has released the June 2026 quarterly confidential feedback reports and IKEAs. If you haven't looked at yours yet, you should do that. These results give you an opportunity to see where your facility stands before the payment year begins. Starting in fiscal year 2027, which is October, your value-based purchasing score is no longer based on a single measure. CMS is evaluating facilities across eight quality measures, and every one of them contributes to your overall performance. Those measures include readmissions, healthcare associated infections requiring hospitalization, discharge to community, often overlooked, long stay hospitalizations, nursing staff turnover, total nurse staffing hours per resident day, the SNP discharge function score, and long stay falls with major injury. The important thing to remember here is you don't have to be perfect in every category, but you need to know where your facility is strong and where you're vulnerable and where you stand. That's exactly what these confidential feedback reports are designed to show you. And remember that the June report isn't the final word. CMS will issue another performance report in August, and the August report is what will be used to calculate your fiscal year 2027 performance score and your incentive payment multiplier, which goes into effect October 1st, 2026. So don't wait until October to find out how your facility did. Review your data, share it with your team, and then use your next few months to improve, see what you can do about it, set plans into motion to make a difference. You know, when CMS first announced this expansion, I think a lot of communities assumed there were simply more measures to keep track of. And there is, but that's not really the biggest change. The biggest change is that your payment is no longer being influenced by one area of performance. It's being influenced by how consistently your organization performs across multiple aspects of resident care. And here's what that means in the real world: you can have an outstanding MDS department, but if your therapy team isn't maximizing functional outcomes or you're struggling with staff turnover, and that's causing bounce back and hospitalizations, your reimbursement can still be affected. This is why I keep saying that reimbursement is not just MDS coordinator or the business office, it is an interdisciplinary effort. Every admission, care plan, discharge plan, therapy session, infection prevention strategy, staffing decision, all those contribute to these quality measures that CMS is evaluating. If your leadership team is only looking at the reimbursement after the claim is billed, then they're behind the eight ball. They're too late. The opportunity to protect revenue happened weeks or even months ago before that claim ever left the building, and that's what we have to try to fix before it gets to that point. Your QM score is not your payment score. That is a huge misconception. It's not how the program works. Your quality measures are simply the starting point. CMS calculates your results for an individual measure, then for most of them, they calculate two different scores: an achievement score, which compares you to other facilities, and an improvement score, which compares you to your own historical performance. CMS gives you whichever score is higher. I actually think that's one of the fairest parts of this program because it rewards facilities that are making improvements, even if they're not at the top of the board yet. These scores are then combined into an overall performance score, and that's your facility's report card. Once every facility has a performance score, CMS ranks them nationally. Your ranking determines your incentive payment multiplier, and that affects your Medicaid reimbursement. So there's an important distinction here. You aren't paid based on your QMs, you're paid based on your performance compared with everyone else. And as an MBS nurse, this is why it matters. Instead of focusing on individual measures, you know, falls and readmissions and GG coding, CMS doesn't do that. R section GG coding is looked at in the whole picture realm. A weakness in one area may offset by strengths in another. And if you ignore several areas, then your overall performance score suffers. I can't stress this enough. You have to be looking at the resident in the correct three-day assessment period. That's why assessment timing is every bit as important as assessment accuracy. Let's talk about that three-day window. I want to make sure we have that right. Admission assessments establish the resident's baseline function. Discharge assessments capture how they performed at the end of the stay. And interim assessments reflect the resident's current functional status. You know, the takeaway is simple. The resident didn't change, the assessment window did. If you're looking at the wrong three days, you're gonna get the wrong score, and that affects everything. So for the admission performance, that's the Medicare five-day PPS, it's the first three days of the Medicare stay. Make sure it's the first three days of the stay, not just the first three admission days. And it's usually the same thing, but not always. Ober admission, first three days of the stay. Combined PPS plus Ober admission, first three days of the stay. Discharge, MDS, look back period, is end of the Medicare Part A stay in the previous two calendar days. Ober discharge is the discharge date and the previous two calendar days. Combined PPS plus Ober discharge is dependent upon the discharge situation, but usually it is going to be the day of discharge in the prior two days. Your IPA and OBRA interim assessments is the ARD plus two previous calendar days, and your quarterly annual significant change, those are going to be your ARD plus your previous two calendar days. Make sure once again you're coding the correct three-day look back. Let's talk about the incentive payment multiplier. I had been an MDS coordinator for a while before I even knew about this term. The incentive payment multiplier is simply the number CMS applies to every Medicare Part A payment your facility receives. Think of your 1.0 as the break-even point. If your multiplier is below 1.0, your Medicare payments are being reduced. If it's above, then your payments are being increased. The important thing to remember is that this is not a random number. It's earned through your facility's overall performance across all eight value-based purchasing measures. Better outcomes lead to a more favorable number, higher number. So while the multiplier may just look like a decimal point, it does represent months of clinical performance documentation and teamwork. Don't chase the multiplier. You don't get a better multiplier by trying to reverse engineer CMS's formula. You can't do it. You get a better multiplier by improving the care your residents receive every day. Focus on the things that you can influence, like readmissions, improving function status, reducing falls, maintaining adequate staffing, and helping residents return safely to the community. Those decisions move your performance score. Let's CMS worry about the math. Your job is to improve the measures that drive it. If you have the slide deck, this is slide number eight. And if you remember one thing from this podcast, I hope it's this slide. If you have access to the slides, we spend a lot of time talking about PDPM because that's what determines what we can bill. But PDPM is only one piece of the reimbursement puzzle. Your Medicare reimbursement is three parts. Your PDPM and your coding and your MDS accuracy determines what you're eligible to bill. The SNF value-based purchasing influences how much of that payment you can keep. And finally, the QRP APU protects the rate itself. You will get deductions of 2% if you do not follow the QRP APU rules. And here's why that matters. You can have perfect, like I just said, you can have perfect PDPM coding, capture every NTA point, optimize every nursing category. But if you fail the QRP, you're going to get 2% taken off. You simply cannot outcode a compliance penalty. And that's what that is. That's why successful facilities don't just focus on PDPM. They're looking at the VBP, the QMs, making sure that they're QRP by running your threshold reports, making sure that you are compliant with those so that you don't get that 2% taken off. Just think of it like this PDPM captures the revenue, VBP preserves it, and maybe helps it with that incentive payment multiplier. And then your QRP APU protects the Medicare rate. If you are missing any of these, you're leaving money on the table. You'll lose money through the 2% deduction, or you'll lose money through your incentive payment multiplier, or you can lose money through uh sloppy MDS coding or MDS assessments that cannot be supported. If you have the slides, this is the MDS elements used for fiscal year 2027 SNF QRP APU determination. If you ever get that warning letter, this is where you're going to go look for dashes. And it's not all of the sections. I'm gonna list those briefly for you. It's part of the sections usually, unless I say otherwise. So it's section A, section B, B0200, B1000, B1300, Section C, D, G, H0400, which is odd, but that's what they want out of section H. I-0900, I-2900. Some questions from section J, K, M, N, O. Basically, they're looking at cog, mood, uh, functional status, swallowing, nutrition, clinical diagnoses, skin conditions, medication use, treatments, and services. The takeaway here is simple. It's not just the MDS coordinator, it's nursing, therapy, dietary, social services activities that all contribute ultimately to whether the facility avoids that 2% payment reduction. You can use this slide as a checklist if you'd like. Or you can just run your threshold reports to make sure that you're completing your MDSs as required. Let's put this APU deduction into perspective. A facility averaging 10 Medicare A residents loses about $50 per day. We'll just use nice even numbers. Over the course of a year, that's $18,000 simply because of the QRP data wasn't submitted correctly. This is a very conservative example. Most facilities average far more than 10 Medicare residents, and the 2% deduction could be higher than that. The good news is it's one of the few payment reductions that's completely preventable. Just make sure your QRP elements on your MDS are filled out, that they're not dashed. In review, again, the eight measures that evaluates the facility's performance for the SNF VBP that applies to your incentive payment multiplier is all cause readmissions, healthcare associated infections, total nurse staffing hours per resident day, staff turnover. The four that are new are potentially preventable long-stay hospitalizations, balls with major injury, discharge to community, and discharge function score. Do you guys work on those monthly? Out of all of those, does your quality committee actively review these? When we're working with facilities, we see that they actively monitor readmissions, staffing, staffing turnover falls, infections, hospitalizations. They do not look at the discharge function score very closely, and the discharge to community gets overlooked also. If these measures are not on your dashboard, I would encourage you to put them there soon. Let's take a little bit of a closer look at the discharge function score. This measure is based, as you know, on the Section G G Self-Care and Mobility Performance at Discharge. The better the resident's functional improvement, the higher the score. Remember when you're coding admissions and you're doing diagnosis for the resident, make sure that you include every diagnosis that you can support and validate because some of them are covariants for the discharge function score and nothing to do with PDPM, but they will go into your algorithm and they will matter in the end. What I really want everyone to remember is that this is not a therapy score. The GG is not a therapy score. Therapy does contribute, but nursing documentation and coding and all your IDT processes work towards this. The biggest problems are coding GG responses inaccurately and not completing the discharge assessment when you're supposed to. The timing, the discharge function scores in your control, meaning that you are to accurately record the outcomes. When the documentation reflects the care that was provided, then your quality scores, your public reporting, and your reimbursement all benefit. Your outcome on an individual resident will vary, but the documentation and accurately capturing it is your responsibility. I just want to give you a reminder that facilities get into trouble when they're using codes like not attempted due to medical condition or leaving an item blank. Because CMS does not ignore that. They use what's called statistical imputations. In other words, they estimate the value for what's missing, they calculate it on their own and they put it in. So using 88 or leaving the GG items incomplete doesn't remove them from the equation. It simply gives CMS the opportunity to make part of the calculation for you. And that's something we want to avoid. A deeper look at the discharge to community deserves more attention. CMS isn't just asking whether or not you discharge the resident, they know you did. They're asking whether the discharge was successful. The resident has to be discharged to the community and remain there at least 31 days. That means no hospital visits, no death. Like we can control that, no return to another institutional setting during that time. You know, this one's not fair because you can't control if your diabetics go home and eat like crazy and get sick, and your lung people go home and then they start smoking again and they get sick. The community doesn't just mean going home, it means any places like assisted living, independent living, but transfers to another SNF, a hospital, or an inpatient rehab facility don't count. I want to make sure I'm clear for residents that go back to the hospital. But for this particular discharge to community QM, what counts as going to the community is home, assisted living, independent living, non-institutional settings. If they go back to the hospital, that's a different issue. Most facilities know their readmission rate, but if I say what percentage of your Medicare residents are discharged to the community and successfully remain there for 31 days, a lot of facilities, communities do not know the answer to that, but CMS does. As I wrap this up, I want to leave you with one final thought. For years, we've spent a tremendous amount of time focusing on PDPM, getting really good at it, and we should. Accurate coding and documentation, capturing all the things. This is essential. But PDPM is only one piece of protecting your Medicare revenue. You know, you can have excellent PDPM and lose money on the APU QRP just from having blanks or dashes. Also, it's these quality measures for the VBP. They're all connected, they all determine how much you are paid and how much of those payments that you bill you get to keep. It's not just the MDS coordinator's responsibility, it's the entire IDT. You have to have every department in the building working together for the same goal. That's quite a process. That's why you're a coordinator. It involves the ancillary people more and more. When everyone understands that these programs all work together with the different teams within the facility, you protect the revenue, you improve the quality outcomes, and you can see things come together if you monitor it. Thank you so much for spending this time with me today. I hope this gave you a practical understanding of how to PDPM, QRP, and VBP all fit together, and more importantly, some ideas you can take back to your facility and start using right away. Thanks for listening, and I'll see you on the next M3 Review Podcast.