Harmony Healthcare Blog

The Importance of Preventing Artificially Low Case Mix Reimbursement

Posted by The Harmony Team on Wed, Mar 19, 2014


Edited by Kris Mastrangelo

The New York State Executive Budget, as proposed by Governor Cuomo, is considering a 2% Cap on increases in New York’s Skilled Nursing Facilities’ Case Mix Index.  The effect on SNF provider’s Medicaid reimbursement (already the largest gap between reimbursement and cost in the nation) could be significant.

SNFs around the country and in New York have seen an overall increase in Case Mix for a whole host of reasons:

  • More attention on increasing the accuracy of CMI due to large Medicaid shortfalls
  • Medically complex patients that require more resources from both nursing and therapy
  • Voluntary programs to find “less intensive” levels of care other than SNFs for the so called “walkie talkies”

New Yorkers know, Case Mix “snapshots” or “picture dates” are captured twice per year in January and July.  This has historically led to “spikes” in the CMI score during those months that caused SNF providers to be scrutinized and their motives to be questioned.

Many other states collect CMI data four times per year (i.e. more in line with the thinking behind the OMRA schedule), and those so called “spikes” are typically much less apparent.

With such large shortfalls between Medicaid reimbursement and actual costs, SNF providers have been forced to look hard at increasing the accuracy of their CMI and ensure that their CMI accurately reflects the clinical picture of the resident.

In 2013, The New York State Office of Medicaid Inspector General began limiting increases to 5%.  Facilities whose Case Mix increased by 5% or more would also be subject to a retrospective audit of Case Mix submission, in order to receive the remainder of their increase.  Thus far the audit process has been found to be effective in the vast majority of the cases, and therefore SNFs are NOT inflating their respective CMI scores.

With the Medicaid Global Cap in place, New York presently has the ability to manage budgetary impacts without imposing a wholesale budgetary solution that will decrease access to long term care and increase re-hospitalizations.

If this provision of Governor Cuomo’s budget is enacted, the most difficult part will be dealing with DECREASES in Case Mix.  What happens if a SNF’s CMI goes down in one picture date by 8%?  How long will it take them to go up to the previous level 2% at a time?

Medicaid Managed Care is on the horizon in many states including New York, already causing concern about the access to necessary care for the frailest nursing home residents.  Continuing your advocacy efforts to elected officials in support of your patients and employees is critical.  I would expect that your elected officials would like to hear about issues involving access to care and reducing re-hospitalizations.

What types of measures are you taking to prevent artificially low Case Mix reimbursement?

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Tags: Case Mix, Case Mix Reimbursement

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