Medicare Advantage plans’ varied interpretations of skilled nursing rules that apply to all beneficiaries in traditional Medicare could complicate federal regulators’ efforts to collect more quality data — and threaten providers’ Medicare Part A payments — clinical and reimbursement experts said Tuesday.

The Centers for Medicare & Medicaid Services hosted a listening session to gather more feedback on its proposal to expand Minimum Data Set quality reporting requirements to all payers. Currently, MDS data is submitted only for short-stay patients covered by fee-for-service Medicare.

While providers have already raised concerns about the additional workload that comprehensive data set reporting would create, Tuesday’s session raised additional questions about how managed care policies and practices might skew both data submission and quality metrics.

CMS is specifically seeking more information on whether adopting a uniform interrupted stay policy for all payers and expanding its leave-of-absence policy to those outside traditional Medicare would be feasible.

While some attendees said the changes could work, many doubted CMS’ ability to force Medicare Advantage plans to follow new rules, which could risk the accuracy of the measures.

MA plans were supposed to begin following the standard interrupted stay policy last fiscal year, but many plans did not, callers said. Instead, some continue to require a new prior authorization even when a patient is returning to the same skilled nursing facility after less than three days in a hospital.

Holding MA plans accountable 

Managed care consultant Nanette Smith said she sees plans continuing to interpret that rule based on their own standards. 

“Some of them do have policies of 12 hours, 24 hours, 36 hours. Every plan does things a little different,” she said. “Some plans say, if a patient exited and went to the hospital, it’s considered a discharge, end of story, unless it’s a planned event or service.”

Another said the “mess” of one-night leaves could be made better by CMS standardization, but any effort to collect data for patients whose stays might be treated differently would require more clear wording and “reinforcement.”

“The managed care companies … would only not need a standardized definition, but they would also have to be held accountable to apply it to the situations,” said Joel VanEaton, executive vice president of post-acute care regulatory affairs and education at Broad River Rehab.

Otherwise, allowing managed care plans to dictate when a patient is considered discharged could hurt providers’ perceived performance on measures tracking discharge function, discharge self-care and discharge mobility.

If plans are allowed to continue dictating when patient stays should end, often against the recommendations of an onsite physician and staff, the pain could be worse. If MDS reporting for non-Medicare patients is added to quality measure calculations, then the ability to avoid a 2% Medicare Part A payment deduction will be skewed by non-Part A data, callers warned.

Others noted changes to Medicare quality reporting also now has an outsized influence on Medicaid rates in states that are using the same metrics to award incentive payments.

Expanding data collection, quality reporting

Laura Liccione, a corporate MDS nurse, said MDS expansions would technically be feasible “because we are already doing a lot of additional assessments” that are simply not transmitted to CMS.

“I think if there were a universal when to do what assessment sort of rule, that would really just help providers and keep things consistent,” she said. “The only negative that we would find has to do with more … complexity and not having control over what the managed care companies decide.”

CMS has already broadened its quality reporting requirements for long-term acute care hospitals, hospital providers, and — starting Tuesday (Oct. 1) — inpatient rehabilitation facilities. But leaders on the call Tuesday said the nursing home changes are still just a proposal.

Consultant Ellen Strunk, working for the company collecting information for CMS, said the agency recognizes that “collecting MDS data regardless of payer would increase burden on skilled nursing facilities.” That’s a point that Jessie McGill of AAPACN raised earlier this week, noting that some facilities could go from reporting MDS data for 10% of patients to 100% of their short stay patients.

While Strunk asked how the broader collection activities might affect workflow and software needs, Tuesday’s callers were more concerned about how calculations from the larger data pool might affect quality ratings, publicly available information and partnerships. 

“One of the burdens we haven’t talked about is the Five-Star burden,” said VanEaton, adding that any skewed star ratings could impact not just Medicare ratings but value-based purchasing participation. “I’m running the risk of having somebody being discharged and not having a score that would have truly represented what their gains might have been had they been able to stay for the full time we thought they should stay.”

CMS held a previous session on this topic in 2023.