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CMS Seeks Greater Enforcement Power in Proposed SNF PPS Rule FY 2025

CMS Seeks Greater Enforcement Power in Proposed SNF PPS Rule FY 2025

compliance policies

Published April 5, 2024

With the changes proposed by CMS for FY 2025, a SNF survey finding of noncompliance will become more burdensome.

In this new rule, issued on March 28, 2024, the Centers for Medicare & Medicaid Services (CMS) proposed several revisions to policies and payment rates used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). Some increases in funding are accompanied by a much greater number of changes that further empower CMS and state survey agencies. One such change will increase flexibility to utilize civil money penalties (CMPs) as a means of enforcement. This will likely make noncompliance more difficult for SNFs to navigate and potentially increase their financial burden.

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This new rule proposes to:

  • Strengthen nursing home enforcement requirements and expand CMS’ authority to impose civil money penalties (CMPs)
    In an attempt to correct inequity in the number of days for per day (PD) CMP imposition across the states, CMS has proposed changing the penalty period. Previously based on the number of days between identification of noncompliance by surveyor and the date of correction by facility, the PD CMP will now accrue based on the date noncompliance is determined to have started prior to the survey date, regardless of whether the issue resulted in resident harm. Other examples of expanded authority are the ability to impose both per instance (PI) and PD CMPs on the same survey; extending the look-back period from the last standard survey to the last three; and allowing multiple PI CMPs to be imposed for the same type of noncompliance.
  • Update SNF PPS wage index by 4.1% and Rebase/Revise the SNF Market Basket
    This proposed increase in the wage index will result in approximately $1.3 billion increase in funding beginning October 1, 2024. The SNF Market Basket update reflects a proposed 2.8 percent increase, a 1.7 percent market basket forecast error adjustment, and a 0.4 percent decrease for productivity.
  • Revise code mappings used to classify patients under Patient Driven Payment Model (PDPM)
    CMS seeks to change the clinical category assignment of four codes added to the Mapping file October 1, 2023. Specifically, E88.10 (Metabolic Syndrome), E88.811 (Insulin Resistance Syndrome, Type A), E88.818 (Other Insulin Resistance), and E88.819 (Insulin Resistance, Unspecified) will be changed from the category of “Medical Management” to “Return to Provider.”
  • Four new social determinants of health (SDOH) items and one modified SDOH item
    Beginning with the FY 2027 SNF QRP, CMS proposed to adopt Living Situation, 2 Food items and Utilities as standardized patient assessment data elements while modifying the existing Transportation data element.
  • Issue a Request for Information (RFI) on potential updates to the Non-Therapy Ancillary (NTA) component of PDPM
    CMS is seeking feedback on the methodology currently being considered for updating the NTA component. These include: Change the years used for data corresponding to Medicare Part A SNF stays, including claims, assessments, and cost reports; Update the methodology to use only SNF Part A claims and the MDS (and not claim types from other settings); and, Modify the overlap methodology “to rely more upon the MDS items that use a checkbox to record the presence of conditions and extensive services whenever possible.”
  • Update the requirements for SNF Quality Reporting Program (QRP)
    Medicare administrative contractors (MACs) would employ the existing process used to validate Medicare Part A fee-for-service claims for medical necessity through targeted and random audits beginning with the FY 2027 program year.
  • SNF Value-Based Purchasing (VBP) Program Preparation for FY 2027 MDS-based Measures
    CMS is proposing several operational and administrative proposals for the SNF VBP program in addition to Value-Based Purchasing (VBP) reduction in payments under the SNF VBP. Those adjustments are estimated to total $196.5 million in FY 2025. FY 2025 (Oct. 1, 2024 – Sept. 30, 2025) is the first performance period for two new measures: Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay) (Falls with Major Injury (Long-Stay)) measure; and Discharge Function Score for SNFs (DC Function) measure.Full details of this proposed rule are available in the CMS fact sheet and the Federal Register.

As your allies, Coretactics’ experts advise you to get ahead of CMS Regulatory Compliance issues. We have a Continuous Survey Readiness Program, and we conduct SNF Mock Surveys to identify negative findings before your next standard survey.

If you’re confused by these proposed changes, we are here to help. Our Coretactics team is knowledgeable in CMS regulations and has extensive expertise in implementing change to sustain results. 

Call us at 518.280.1343 or Email us!