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On October 1, 2019, CMS implemented the new SNF Medicare Part A reimbursement, the Patient Driven Payment Model, or PDPM for short. These medicare reimbursement changes have significantly affected the way the daily SNF PPS, or Skilled Nursing Facility Prospective Payment Systems, rates are determined.

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The shift from the RUG-IV case-mix model to a patient driven payment model is marked by goals to:

  • Improve payment accuracy and ensure appropriate treatment by focusing on the individual patient, rather than volume of services provided
  • Reduce administrative burden on providers
  • Improve skilled nursing facility payments without increasing total Medicare payments

While RUG-IV categorized patients into a single, volume-driven case-mix group, PDPM focuses on the individualized needs, characteristics, and goals of each patient.

Experts have noted that in order to maximize PDPM reimbursement rates with these changes, facilities needed to shift the emphasis on therapy volume to more comprehensive care that includes therapy, nursing, and non-therapy ancillaries. This lends itself to potentially more complex, higher acuity case mixes that may require a strategic shift in focus for facilities to remain fiscally healthy and dedicated to providing the best possible care for patients.

Now that PDPM has been implemented, skilled nursing facilities are executing their plans to meet all the requirements and optimize PDPM reimbursement. Leveraging technology during this shift and utilizing PDPM training for nurses can help you manage your staff’s development and standardize your processes.

Do you have all the tools needed to successfully thrive throughout the regulatory changes? Relias has compiled several resources to aid in your quest to prepare for compliance with the patient driven payment model PDPM. Use the resources below to ensure that your practice is following the PDPM guidelines!


In Our Evolving PDPM/PDGM World, Could Adding a Specialty Be a Game Changer?

Adding a specialty to your repertoire in order to have more control, provide better outcomes, and work within the playbook you’ve been given will be the matter at hand in a growing PDPM world.

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Your PDPM Questions Answered - Part 1: Laying the Foundation

Ron Orth, RN, CHC, CMAC answers questions from part one of our six part PDPM webinar series, Laying the Foundation.

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Your PDPM Questions Answered - Part 2: Therapy Case Mix Groups

Ron Orth, RN, CHC, CMAC answers questions from part two of our six part PDPM webinar series, Therapy Case Mix Groups.

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Your PDPM Questions Answered - Part 3: Nursing Case Mix Groups

Ron Orth, RN, CHC, CMAC answers questions from part three of our six part PDPM webinar series, Nursing Case Mix Groups.

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Your PDPM Questions Answered - Part 4: Non-Therapy Ancillaries Case Mix Groups

Ron Orth, RN, CHC, CMAC answers questions from part four of our six part PDPM webinar series, Non-Therapy Ancillaries Case Mix Groups.

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Your PDPM Questions Answered – Part 5: Assessment Requirements

Ron Orth, RN, CHC, CMAC, answers questions from part five of our six part PDPM webinar series, Assessment Requirements.

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Your PDPM Questions Answered - Part 6: Putting It All Together

Ron Orth, RN, CHC, CMAC answers questions from part six of our six part PDPM webinar series, Putting It All Together.

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  • Will managed care assessment be done as a 5-day separate assessment that is not transmitted and we do Admission only on those?

    At this time CMS has not issued any change in policy related to submission of PPS assessments. PPS assessments (5-day) completed under PDPM for non-Medicare beneficiaries should not be submitted unless otherwise directed in the future by CMS. It is advised to continue to separate the 5-day from the OBRA Admission assessment unless otherwise instructed.

  • The 2% reduction in therapy - is it designed to keep stays short?

    CMS analysis indicates that therapy services decreases during a Medicare stay. The 2% reduction is implemented to correspond with this reduction of services.

  • We provide trach and vent care in Skilled Nursing Facilities. Most of our patients are Medicaid. How might this impact us?

    This would be a state specific question and depends on your specific state’s reimbursement system and what plans once PDPM is implemented. Medicaid specific questions will need to be addressed directly to the respective state.

    There may be no immediate impact as CMS will continue to support the RUG III/RUG-IV systems until further notice. Also, an Optional State Assessment (OSA) will be implemented with the PDPM for states that require additional assessments.

  • Will therapy still need to track and report co-treatment minutes on the MDS?

    Yes, the MDS will still have separate entries for individual, group, concurrent, and co-treatments.

  • We often receive transfers from other LTC facilities wishing to admit to our facility. We would be doing a 5 day for our facility. The other facility already received the variable per diem rate adjustment. Does that preclude us from receiving the base rate adjustment? Or would we still be able to utilize the base rate adjustment?

    The variable rate adjustments are based on Medicare stays. Since the resident would be new to your facility, this is considered a new Medicare Part A stay, requiring a new 5-day assessment. The variable rate adjustments would be reset to day 1.

  • Are MD certs required for 5-14-30-60-90 still or just for the 5 day?

    SNF Physician certification and recertification regulatory requirements are independent of the current RUG payment system and the upcoming PDPM. Physician certifications would still be required upon admission. Recertifications would still be required by day 14 and no later than every 30 days thereafter.


As if the PDPM changes weren't enough for organizations to navigate, Phase 3 of the Requirements of Participation (ROP) began on November 28, 2019. The ROP is a set of regulations put in place to create quality and safety standards that all long-term care providers must meet to participate in Medicare or Medicaid. The three phases that have been rolled out over the past few years are the first time the ROP has been updated since 1991, and they have caused some major shockwaves. The third phase places an emphasis on trauma-informed care, infection prevention programs, competency development and more. If you’re still worried about Phase 3 of the ROP, here is a collection of resources to help you get prepared.

Requirements of Participation Phase 3 Basics - What You Need to Know Before November 28, 2019

Watch this webinar to see a deep dive into Requirements of Participation Phase 3 and how you will need to adapt the business of care to be in compliance.

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Get on Top of RoP: How Relias Prepares You for Meeting Competency Requirements

If a surveyor were to show up to your door on November 28, how would you show that you’ve met these requirements?

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Trauma-Informed Care: Implementing a Meaningful, Person-Driven Program for RoP Phase 3

During this webinar, we provide guidance around the implementation of the six principles of a trauma-informed care program as it affects the whole organization and discuss the need for individualized approaches to care.

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Leveraging technology during this shift can help you manage your staff’s learning and standardize your content and processes. Relias can help you maintain compliance with PDPM and meet the ROP competency requirements with our PDPM training for nurses.

  • Proper Coding: Relias’ MDS courses are regularly updated and will enable your staff to understand the RAI process, the components of the MDS, and offer the opportunity for CMAC certification.
  • Drive Competencies: Establish a baseline competency based on your population mix using Relias Assessments and provide targeted education to develop competency across the organization.
  • Change Management: Relias offers education and tools, such as Policies & Procedures Management, to help ensure a smooth transition and adoption of the new practices.

Click the button below to speak to a Relias representative to receive a personalized demonstration on how to incorporate our tools and education for continued training on PDPM and Phase 3 of the ROP.

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