Addressing Skilled Nursing Operations During the COVID-19 Pandemic

The COVID-19 pandemic has made significant impacts on the healthcare landscape as we know it. These various impacts have affected every level of patient care delivery in some way, and for the skilled nursing industry, challenges are created in both operations and in reimbursement. Skilled nursing facility operations have changed drastically to accommodate and provide crucial care to the communities they serve during the COVID-19 pandemic. Combine new COVID-19 changes with reimbursement challenges due to adjusting to the Patient-Driven Payment Model (PDPM), and the skilled nursing landscape becomes even more complex for providers.

Be aware of COVID-19’s impact on Medicare policy and PDPM

COVID-19 immediately influenced changes in Medicare policy to create more availability of hospital beds for the treatment of those infected with the virus. One of these changes is waiving the 3-day qualifying stay for a skilled nursing rehabilitative stay. During this pandemic emergency, a 3-day hospitalization is not needed. Be mindful of the changes in how organizations track Medicare days since the 60-day break is not necessary, how to document a skilled need without a qualifying acute stay, and understanding how to fill out the UB04.

COVID-19 also has an impact on the new payment model PDPM, imposed by Along with a potential increase in Medicare Part A volume is an increase in Respiratory Failure Diagnosis. There will be an increased need to ensure documentation compliance with use of oxygen, recording shortness of breath while lying flat, and capturing seven days of respiratory treatments. If your facility has ventilators, understand that respiratory arrest can be coded. If a patient is still on COVID-19 precautions, isolation can be captured. Keep in mind that not only is having accurate clinical documentation important during the COVID-19 pandemic, but also having enough Durable Medical Equipment available to both provide care and capture its delivery on the MDS.

Know what to do if you are short on staff

An obvious impact of COVID-19 is its effect on staffing. Facilities should be prepared for shortages of nurses, CNA’s, respiratory therapist and administrative staff due to COVID-19 transmissions despite increased staff surveillance of symptoms prior to working each shift. Staff will need initial and ongoing education on infection control practice and COVID-19 resident surveillance and treatment. Measures to reduce transmission risk include restricting only essential staff in the building and checking staff temperatures and oxygen saturation before their shift. If able, utilization of telehealth ensures physician care can be provided with adding risk of person to person exposure. Also, review your pandemic plan to check for regulatory compliance. The CDC and CMS continue to release guidance to healthcare providers on pandemic practice to protect both staff and residents. The Quality Improvement Organization (QIO) Program has compiled lists of CDC and CMS guidance you can reference.

Monitor efficiency of operations to avoid procedural gaps

Monitoring processes and workflows to avoid any potential gaps in operations is crucial for keeping your facility on track during this time. Providers should consider monitoring and managing productivity of revenue cycle staff through daily check-ins with supervisors using web-conferencing software.  Supervisors should set expectations of productivity requirements and hold their teams accountable for their responsibility in the revenue cycle process. Some suggestions of important metrics to keep track of:

• Medicare patients to verify
• Number of patients to pre-bill review
• Volume of claims to follow-up on and resolve
• Remits and dollars to post

Supervisors can also facilitate virtual group meetings to discuss triple check processing, productivity progress and any challenges encountered. It is important to use EMR dashboards, if available, to monitor workflows and volumes. If dashboards are not available through the EMR, coordinate with IT support to build an external dashboard to be updated on a daily and weekly basis.

To adapt to the current COVID-19 and PDPM situation, efficiency during the insurance verification and authorization process is key. As employees are challenged to work in a remote environment, productivity and accuracy will be critical to combat reduced staffing and wait times among insurance facilities. This can be done by leveraging the use of portals and batch eligibility checks.

Stay compliant with current and new CMS regulations

CMS is keeping a watchful eye on compliance with pandemic infection control practice. Facilities need to understand the necessary steps to be taken to avoid a jeopardy tag.  Lessons learned from Kirkland Nursing Home in Washington state emphasizes the need to treat patients timely, report relevant infections to authorities, and have a backup plan for provider care should someone get sick and not be able to provide services. CMS released a facility pandemic preparedness checklist and are using this as guidance in infection control surveys.

COVID-19 has a direct impact on all operational processes in skilled nursing, and facilities need to make the proper changes to adjust. However, facility staff may be potentially overwhelmed with various obstacles related to COVID-19. Because of this, consider outsourcing key facility functions, such as partial or full billing processes, education of staff, and reviewing PDPM documentation for compliance as well as pandemic plans. This will allow staff to concentrate on providing high-quality patient care during this time.