The state fiscal year (SFY) 2022 Nursing Home Methods of Implementation included a hold harmless provision in which facilities would be reimbursed for any rate reduction in excess of $2 per patient day. This resulted from the transition from Resource Utilization Groups (RUGs) to patient driven payment model (PDPM) acuity systems. This communication includes revisions to the quarter 1 (Q1) 2022 payments that were initially shared in November 2022, and new information for payments for Q2 2022.

The purpose of the reports is to calculate additional payments due to providers that had per diem payments under the PDPM less than they would have been under the RUGS system. Federal data as of September 30, 2022, was used for the Q1 2022 report and December 31, 2022, for the Q2 2022 report.

Q1 payments were originally remitted in December 2022. Previously, hold harmless reports were delivered to nursing home providers illustrating the difference between RUG and PDPM classifications. However, the logic used to determine RUG values applied a Centers for Medicare & Medicaid setting referred to as “MCAR3” instead of applying the “Other” setting. The revised Q1 2022 hold harmless reports use the “Other” setting and result in increased payments to providers due to the higher calculated RUG payment compared to the PDPM payment. Additionally, the Wisconsin Department of Health Services (DHS) incorporated other case mix index (CMI) corrections such as removing incorrectly included hospice and ventilator days. These corrections result in lower payments for some providers. DHS will recoup all original Q1 payments, along with remitting payment for revised Q1 and Q2 reports.

Providers eligible for payments had an average daily decrease of more than $2 per patient day, per the hold harmless provision, SFY 2022 Methods Section 2.60.

Next steps

• If your facility is eligible for a revised Q1 payment, you will receive the revised Q1 report under the “Hold Harmless Report” event on your Wisconsin Nursing Home Rate Setting (WINHRS) stat log for fiscal year ending 2020.
• If your facility is eligible for a Q2 payment, you will receive the Q2 report under the “Hold Harmless Report” event on your WINHRS stat log for fiscal year ending 2020.
• If your facility is not eligible for payment, you may request a copy of your report by emailing WINHRSHelpDesk@mslc.com. Include your POP ID in the request.

DHS will issue payments to facilities for services rendered by fee-for-service providers, as per the facility’s report. Managed care organizations (MCOs) are required to submit payments to facilities for services rendered by their network providers. MCOs have been provided a report detailing how much they owe each facility.

If you believe a calculation has been made in error, contact your assigned auditor before November 2, 2023. DHS will issue payments and full recoupments no earlier than November 3, 2023. Payments will be processed via ForwardHealth and will show up in your facility’s remittance advice.

Please contact kate@whcawical.org with any questions.