It’s Complicated: Part A Medicare Utilization ReviewJune 8, 2021
Part 5 of a 6-part series titled “Simple and Easy: Winning in PDPM Payment and Regulatory Strategies”
Presented By: Leah Klusch, RN, BSN, FACHCA, Founder and Director of The Alliance Training Center
Date: June 8, 2021 at 1:00PM E/ 12:00PM C
Part 5 of a 6-Part Series
October 1, 2019 began a new Part A payment process which requires the skilled facilities to use new criteria and data to establish Medicare skilled benefit at the time of Admission. The reliance of the facility on therapy delivery and outcome data along with AOL scores is no longer a factor. Medicare payment is now influenced by a very diverse elder specific calculation from a large data base on the Admission or IPA Assessment. Facilities are required to review Part A Medicare cases during the stay to establish the continued need for skilled nursing or skilled rehabilitation. This session will review the five areas of data that create payment levels and the skilling definition in the Medicare Benefit Policy Manual. Review of these items from the MOS data base makes the utilization process more complex and very interdisciplinary. Case examples and a meeting formats will be discussed as well as newly revised eligibility and skilled criteria definitions. Records of UR meetings are very important and a review of formats will be part of the program.
Key Webinar Learnings
- Review the changes in the U.R. process precipitated by the implementation of the PDPM payment system.
- Discuss compliance audit and issues related to U.R. activity and regulatory standards.
- Describe the structure of the interdisciplinary U.R. process vs. the therapy UR process.
- Review the record keeping requirements for the Utilization Review process.
- Discuss the use of utilization data for outcome documentation.