SNF COVID-19 Considerations for Tracking Additional Expenses & Lost Revenues

Thoughtware Alert May 15, 2020
Nurse and patient holding hands

Skilled nursing facilities (SNF) need to be diligent and thorough in tracking expenses and lost revenues related to the SARS-CoV-2 virus and the incidence of COVID-19. SNFs should strive to clearly document and identify all “activities” that substantiate the need for additional COVID-19 funding to sustain their operations. SNFs are incurring additional costs each day responding to the changing regulatory and care environment, which includes additional supply and labor costs in multiple departments. The additional labor costs are requiring incentive pay arrangements such as overtime, attendance bonuses and hiring contract staffing at much higher rates. This has left many facilities overwhelmed and unsure where to start.  

The following is a sample checklist by department that could be used as a starting point to fully evaluate the financial effects of COVID-19 on your SNF operations. This isn’t an all-inclusive list, as each facility may have unique situations and circumstances that dictate what effects COVID-19 is having on their operations.    
 
Administration

  • Employee Screening: Account for the time and wages of employees who are assigned to the task of screening all who enter the premises separately. Screening is now recommended at the beginning of each shift to report if an employee falls ill and becomes absent. If staff are working more than an eight-hour shift, an additional screening must be done no later than 12 hours after the initial screening. This includes anyone who might enter the building including employees, visitors, contract staff and vendors. 
  • Security: Account for staff and equipment that has been purchased to secure buildings and manage visitors, vendors and other healthcare workers who come on site.  
  • Workforce Constraints: Account for costs due to increased absenteeism of employees either due to sickness or caring for family members. Providers are raising concerns about the workforce effect in skilled nursing due to the cascading effect of school closures and the reduced number of child care options. This requires SNFs to cover additional shifts in certain departments with a blend of overtime and contract staffing to meet additional demands.  
  • Human Resources: Account for time related to developing additional policies for employees, performing additional onboarding of temporary staff and agency staffing and managing scheduling.
  • Employee Engagement: Account for the purchase of meals, gift cards, transportation cards, etc., to motivate employees for their continued efforts.  
  • Enhancing IT Infrastructure: Account for upgrading and expanding internet services and purchasing additional equipment such as iPads, Kindles and cellphones to allow residents to communicate with family members.   
  • Remote Work: Account for all the expenses related to nonessential personal who may be working from home or other locations. For organizations that have allowed certain employees to work remotely, SNFs are incurring extra expenses related to buying extra laptops, software licenses, monitors, printers, scanners and other forms of wireless connectivity.
  • Management Oversight: Account for the time spent to evaluate current issues and educate staff members on evolving policies and procedures and the time spent on communications to multiple parties including residents, staff and family members.  
  • Financial Accountability: Account for the time associated with completing forms and setting up systems to track payments related to COVID-19 funding, including accelerated payments and grant money, applying for loans, etc. Also, account for time spent creating policies and procedures around tracking COVID-19 funding use.   
  • Compliance Reporting: Account for time spent on collecting information and mandatory reporting to state and other regulatory agencies.  
  • Consulting Expenses: Account for costs being incurred from multiple parties to consult on emergency responses due to COVID-19 in areas including communications, regulatory, legal, operational, financial, clinical and in-service instructors.  
  • Therapy Services: Account for decreased therapy services related to patient isolation status, decreased admissions and absence of group and concurrent services.  
  • Program Closures: Account for certain additional service offerings such as adult day centers and outpatient therapy services that have been discontinued during the pandemic.  
  • Creating a COVID-19 Journal: Maintain an ongoing log of all communications, education and costs associated with the pandemic. Make sure each item has a corresponding entry for either lost revenue or increased expenses. 
  • Public Relations: Account for time managing external communications and the reputational risk as a result of the pandemic. 
  • Salaried Employees: Consider maintaining a log of hours worked by salaried employees as a result of the pandemic.  

Billing

  • 1135 Waivers: Account for time spent screening and reviewing between clinical and billing personnel related to proper use of 1135 waivers. Billing staff may have to make manual edits in the billing system to accommodate waivers. For example, most billing systems are not set up to accommodate billing for an extra 100 days and could trigger errors. Therefore, make sure to account for the time spent resolving any issues with the Medicare Administrative Contractors to get these unusual claims to pay correctly.  
  • Lab Specimens: Account for clinical time collecting lab specimens as well as documentation and tracking for the SNF to bill. For example, some SNFs are having to complete venipunctures because, in certain parts of the country, lab employees aren’t coming to the building. SNFs can bill for these items; however, the payment received may not be enough to recoup the efforts put forth to gather, track and bill. 
  • Telehealth: SNFs can bill Medicare Part B for the originating site fee with reimbursement. However, amounts billed might not make up for all the costs incurred for labor to assist with the visit, documentation and billing costs.    
  • Ongoing Education: Account for all the time spent researching and keeping up with constant changes, which includes reading emails from Medicare and managed care payors and industry associations and participating in teleconferences and webinars. 

Nursing

  • Infection Control Procedures: Account for the costs associated with implementing additional infection control procedures mandated or recommended by the CDC and CMS, which includes staff time for ongoing education, policy and procedure revisions and supervision. 
  • Personal Protective Equipment (PPE) Utilization: Account for all the costs associated with PPE. SNFs are experiencing additional use of masks, gowns, gloves and face shields that are in short supply. Supply shortages are leading to increases in standard prices for these supplies. In addition, SNFs need to track donations of PPE supplies from various agencies and businesses separately.  
  • Nursing Documentation: Account for the time spent monitoring and documenting resident conditions for Medicare coverage secondary to COVID-19 and the 1135 waiver.  
  • MDS Redeployment: Account for personnel moved to alternative duties. For example, an MDS coordinator may be reassigned to a unit/household, so additional staff time is required for MDS reporting. 
  • Nursing Equipment: Account for the purchases of additional nursing supplies such as oxygen, blood pressure cuffs, thermometers, pulse oximeter, stethoscopes, etc. 
  • Resident Monitoring: Account for all the clinical and supervisory time performing additional monitoring on the entire current resident population, including residents with comorbidities that result in compromised respiratory status.  
  • Resident Screening: Account for all the time and supplies spent screening residents separately from normal patient care time and supplies. 
  • Resident Isolation: Account for all the costs associated with keeping COVID-19-positive residents in isolation, including additional PPE required for all staff who enter the rooms. Similarly, account for the licensed nursing staff time for appropriate assessment of residents every shift. 
  • Telehealth: Account for all time spent to assist with physician telehealth visits. 

Dietary

  • Noncommunal Dining: Account for labor costs to deliver meals and monitor eating on an individualized basis. Similarly, account for the increased equipment costs, e.g., additional warming carts and overbed tables needed to serve meals in rooms or at doorways.   
  • Employee Meals: Account for all the costs for providing meals during shifts to all employees so they don’t leave the building to reduce exposure.
  • Isolation Meals: Account for additional costs for disposable service items for residents in isolation.  

Activities

  • Individualized Activities: Account for labor costs for employees who are conducting more individualized activities with residents, since group activities have been discontinued.
  • Resident Communications: Account for labor costs to assist residents with communication with family during visitor restrictions.

General Services

  • Housekeeping Costs: Account for labor and supply costs for completing more frequent cleaning and additional sanitization of surfaces and deep cleaning and sanitization of care areas.
  • Waste Services: Account for waste removal costs associated with additional PPE disposal.
  • Room Changes: Account for costs for moving residents in the facility between rooms to properly isolate patients as needed.
  • Central Supply: Account for hours to order, track and count PPE supplies in addition to the increased cost of supplies.  

Social Services

  • Resident Support: Account for time fielding family and resident questions, providing increased emotional support and facilitating communication to external parties outside the facility.  

Reduced Revenues

  • Reduced Admissions: Account for the loss of revenue associated with the decrease in Medicare and managed care census as a result of deferral of all elective surgeries and not admitting residents to reduce exposure to current residents. SNFs should track admissions not accepted. Similarly, SNFs could compare year-over-year revenue or compare budgeted to actual revenue.  

A day will come where all providers will need to provide an accurate accounting of the additional resources they’ve received from various programs, including the PPP and their portion of the Public Health and Social Services Emergency Fund, and where they spent these resources. It will be very important to demonstrate that no additional expense or lost revenue was reimbursed more than once. Remember, the accounting records will need to accommodate both COVID-19 pandemic reporting requirements related to stimulus/relief received as well as Medicare and Medicaid cost reporting and tax returns. At this time, we simply don’t have sufficient guidance regarding what those reporting requirements will be, including how COVID-19 expenses and revenues will be treated for Medicare and Medicaid reimbursement. We recommend sufficient segregation and detail in the accounting records of the incremental costs to address COVID-19 to accommodate both reporting purposes.

As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication. For more information, visit our COVID-19 Resources for Healthcare page, contact your BKD Trusted Advisor™ or use the Contact Us form below.

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