Underreporting of Medical Director Hours
In the second quarter of 2022 (the most recent data available), 37% of Skilled Nursing Facilities nationwide reported no medical director hours to the Centers for Medicare & Medicaid Services (CMS) through the Staffing Data Submission Payroll-Based Journal (PBJ) system, despite federal laws and regulations requiring a physician as medical director and mandatory reporting of their hours worked. According to the Society for Post-Acute and Long-Term Care Medicine (also known as “AMDA”), significant underreporting of medical director hours has been an issue as far back as 2019.1
Medical Director Role and Requirements
Required by law under Title 42, Section 483 of the Code of Federal Regulations, Title 42 CFR §483.75 contains the general description of Medical Director services in SNFs, and F841 Responsibilities of Medical Director (in the Administration regulatory group) requires that each nursing facility designates a physician who will act as the Medical Director, responsible for implementation of resident care policies and coordination of medical care. The accompanying Interpretive Guidance (IG) has been greatly expanded under updates to CMS Requirements of Participation (RoP), specifying that facilities must identify how the medical director will fulfill their specific responsibilities outlined in the regulation, as part of a job description or through a facility policy.
AMDA defines the role as follows: “The medical director is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The medical director serves as the clinician who oversees and guides the care that is provided, a leader to help define a vision of quality improvement, an operations consultant to address day-to-day aspects of organizational function, and a direct supervisor of the medical practitioners who provide the direct patient care.”2 AMDA categorizes the services of the medical director into nine functional areas: Administrative; Professional Services; Quality Assurance and Performance Improvement; Education; Employee Health; Community; Rights of Individuals; Social, Regulatory, Political, and Economic Factors; and Person-Directed Care.
Medical Director Impact on Quality Outcomes
The Federal Medical director requirements have been informed by research that links the medical director’s level of involvement with quality outcomes. In research done by PointRight, there were correlations between medical director hours and short-stay patient outcomes, including hospital readmission and short-stay quality measures for falls, pressure ulcers, and antipsychotic use. Facilities with high-acuity resident populations and high post-acute care patient volume usually require greater involvement of the medical director to achieve better outcomes.
PBJ Reporting is Required, but Challenging
Facilities are required to report medical director hours through PBJ, but facilities may have difficulty with this due to employment arrangements (medical directors are often contractors rather than employees), the complexity of tracking their hours, and internal PBJ reporting policies/processes. CMS acknowledges the difficulty and has specific requirements and guidance for facilities in their PBJ policy manual.3
“Medical Directors and Consultants
For medical directors, CMS understands it may be difficult to identify the exact hours a physician spends performing medical director activities versus primary care activities. Data reported shall be auditable and able to be verified through either payroll, invoices, and/or tied back to a contract. Facilities must use a reasonable methodology for calculating and reporting the number of hours spent conducting primary responsibilities. For example, if a medical director is contracted for a certain fee (e.g., per month) to participate in Quality Improvement meetings and review a certain number of medical records each month, the facility shall have a reasonable methodology for converting those activities into the number of hours paid to work. For consultants, data reported shall be auditable and able to be verified through either payroll, invoices, and/or tied back to a contract. We understand it may be difficult to identify the exact hours a specialist contractor (e.g., non-agency nursing staff) provides services to residents. However, there shall be some expectation of accountability for services provided. Facilities must use a reasonable methodology for calculating and reporting the number of hours spent conducting primary responsibilities, based on payments made for those services. Reminder: Practitioner (e.g., physician, nursing practitioner) visits to residents billed to Medicare or another payer, hours for services provided by hospice staff and private duty nurses shall not be reported.”
In addition to its impact on quality outcomes, not meeting medical director requirements may result in F841 survey deficiencies and/or related to quality of care F tags. Failure to meet PBJ reporting requirements may have compliance implications for facilities. And as we know, CMS uses reported PBJ data to develop quality metrics and inform Five-Star system changes.
In September 2022, the House introduced a bipartisan bill that would require CMS to revise regulations and specifically require facilities to report the identity of medical directors and related information. Supported by AMDA and the AMA, the Nursing Home Disclosure Act (HR 8832) would also require CMS to publish medical directors’ information on the Care Compare online tool to improve public transparency, aiming to ensure that facilities are held accountable for hiring qualified medical directors and to help consumers make more informed long-term care choices, according to its sponsors, Reps. Mike Levin (D-CA) and Brian Fitzpatrick (R-PA).4
Some organizations have been advocating for greater transparency around medical directors for years, and some have surmised that the underreporting of medical director hours may have contributed to the development of this proposed legislation. Some nursing facility providers have expressed concern about the additional burden of the reporting that would be required.
What Facilities Can Do
Make sure you “get credit” for all the great work you and your medical director are doing! Here are some specific steps you can take:
- Share this information with your teams and be sure they understand the importance of medical director involvement and PBJ reporting.
- Have a medical director job description and implement a process for tracking medical director activities and hours.
- Ensure medical director hours are reported through PBJ. If your medical director is not in your payroll system, be sure you include their tracked hours.
- Be prepared to demonstrate compliance through your documentation, and practice simulated surveyor interviews with your medical director and key personnel.
- Tell your story! How are you collaborating with your medical director to improve quality outcomes? Get involved in advocacy efforts and encourage your medical director to do the same.
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1 AMDA – The Society for Post-Acute and Long-Term Care Medicine, “Ask Your Representative to Support the Nursing Home Disclosure Act,” September 16, 2022.
2 AMDA – The Society for Post-Acute and Long-Term Care Medicine, “The Nursing Home Medical Director: Leader & Manager,” March 1, 2011.
3 Centers for Medicare and Medicaid Services (CMS), “Staffing Data Submission Payroll Based Journal (PBJ)”, page 13, October 12, 2022.
4 McKnights Long-Term Care News, “Nursing Homes Would Report Medical Director Data to CMS Under New Bill,” September 16, 2022.