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There are length of stay rules that govern skilled nursing facilities, which are reimbursed for up to 100 days of care per calendar year (Medpac.gov, online). If the patient requires more than 100 days of care, that patient is deemed by the government to be in need of long-term care (LTC), for which Medicare does not reimburse providers for. The patient costs associated with skilled nursing facilities is often offset by a Medicaid component, and if the patient has any financial responsibility, it is minimal. However, to qualify for the Medicaid component, the patient must be indigent, and if the patient owns any property, the state in which the patient receives the skilled nursing or long-term nursing care in, which made payments for the patient shares, can seize the patient's assets at death, and sell the assets (usually property) to offset its losses.
The resource utilization groups by which the government determines the RUG payment to the skilled nursing facility, are classified by 53 groups of diagnoses that are related to skilled nursing levels of care (Medpac.gov, online). The groups are assigned reimbursement levels (refer to diagram above), and are periodically updated by the group as is determined by the government with regards to inflation in the cost of the RUG (Medpac.gov, online). The RUGs are tracked by the government, because the patients who fall within a certain RUG should have similar charges for utilization of care (Medpac.gov, online).
Again, documentation must support the RUG. For instance, when physical therapy or another ancillary service is utilized by the patient, the number of minutes, or hours that the patient receives in service will impact the...
Therefore, the documentation must support the charges submitted for reimbursement, as well as the need for services (Medpac.gov, online).
As is demonstrated, the PPS reimbursement for SNF should be such as to ensure a high quality of care delivered by professionals in the setting. It was what the industry lobbied for, and the improved quality of care was what the beneficiaries expected to see come about. It is too soon for to determine the extent to which the quality of care has improved, but studies are being conducted that should reveal if the efforts to reimburse skilled nursing facilities on a more equitable basis through the PPS has been successful.
References
HHS.gov (2009), Centers for Medicare and Medicaid Services, found online at http://www.cms.hhs.gov/SNFPPS/01_overview.asp,retrieved26 February 2009. http://www.questia.com/PM.qst?a=o&d=113359217
Kolb, P.J. (2003). Caring for Our Elders: Multicultural Experiences with Nursing Home Placement. New York: Columbia University Press. Retrieved February 27, 2009, from Questia database: http://www.questia.com/PM.qst?a=o&d=113359217
MEDPAC.gov (2009), Skilled Nursing Facility Payment System, found online at http://www.medpac.gov/publications/other_reports/Sept06_MedPAC_Payment_Basics_SNF.pdf,2006,retrieved 26 February 2009. http://www.questia.com/PM.qst?a=o&d=5001926665
Ubokudom, S.E., Woods, J.A., & Schalk, L.S. (2002). The Effects of Case-Mix Reimbursement on Ohio Medicaid Nursing Home Costs. Policy Studies Journal, 30(3), 321+. Retrieved February 27, 2009, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001926665
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