As we all continue to adjust to the changes brought on by the implementation of the Patient-Driven Payment Model (PDPM), it's understandable that we're going to have questions. One area that many SNF providers have been looking for clarification on is how and when to use the Interim Payment Assessment (IPA).
Is this something that is optional? When is the right time to complete an IPA? Does it matter if there's not going to be a change in reimbursement? What's the outlook for the IPA in the SNF community? Are there any best practices we can implement to help support our teams?
While the answers to these questions could and probably will change over time, clarity can be found by digging into the current information provided by the Centers for Medicare & Medicaid Services (CMS).
Are Interim Payment Assessments Mandatory?
As of now, completing an IPA is optional and entirely up to the discretion of the provider. Outlined in Chapter 2 of the RAI User Manual, the assessment is clearly listed as optional.1 If an IPA is not completed, the reimbursement determined during the intake assessment will carry through the entire duration of the stay.
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When Should We Complete an Interim Payment Assessment?
CMS lays out the vision for how they see the IPA being used and the roles it should play.
- "...we note that while an SNF’s decision to complete the IPA itself is indeed optional, the SNF’s underlying responsibility to remain fully aware of (and respond appropriately to) any changes in its resident’s condition is in no way discretionary." 2
- "We continue to believe that it is necessary for SNFs to continually monitor the clinical status of each and every patient in the facility regularly regardless of payment or assessment requirements and we believe that there should be a mechanism in place that would allow facilities to do this."3
- "We believe this discussion clearly establishes the IPA as one of the vehicles that the SNF can utilize in the course of carrying out its ongoing patient monitoring responsibilities."4
CMS explains that it's looking for the IPA to serve as a tool to help SNFs track the status of a patient's conditions and needs to provide a higher level of care.
So, when should we complete an IPA? The first obvious answer is when a change in status results in a change in reimbursement. If the patient's condition changes in a way that would require different treatment with higher costs, an IPA can make sure you're getting paid appropriately.
Additionally, this also means we should be conducting an IPA even if it results in a lowered reimbursement. While this isn't ideal, it seems to be the most in line with the minimal guidance given by CMS.
A great way to get your team on the same page with IPAs is to create a checklist that outlines simple indicators that you'd like to trigger an IPA. This helps to get the whole team on the same page and create an easy avenue for updates if and when CMS rolls out new or amended guidance.
For the sake of completeness, we do want to point out the more literal answer to the question of when you should (or can) complete an IPA. An Assessment Reference Date (ARD) may be set for any date beyond the ARD of the initial assessment. From there, the IPA must be completed within 14 days of the new ARD.5 Any payment changes resulting from an IPA will begin on the ARD that is set for the IPA, not when the IPA is completed.
What If There is No Expected Change in Reimbursement?
If the IPA is optional and the change in the patient's condition doesn't result in a positive or negative change in reimbursement, should we still conduct an IPA? The answer to this question is addressed by CMS.
- "Moreover, the discussion of the IPA in the FY 2019 SNF PPS final rule (83 FR 39233) clearly envisions a role for this assessment that is not strictly limited to payment alone."6
While the choice is still up to us, CMS is clear that it's looking to create a tool that helps to capture changes in the patient's condition and treatment. The advantages of proactivity here create better records, more protections for audits and takebacks, and better aligns us with the vision of CMS regarding the IPA.
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