How to Optimize NH Incentive Payments

Regulation | December 09, 2020 | by Nicole Fallon

The U.S. Department of Health and Human Serivces (HHS) issued Nursing Home Infection Control (NHIC) incentive payments for the September performance period and since their distribution in November, many questions have been asked about who received them, who didn't, how much was recieved and why? LeadingAge reached out to HHS on behalf of a sampling of our member nursing homes who didn't receive a September payment but believed they should have based upon the criteria of controlling the infections and minimizing deaths in their nursing homes. HHS recently provided some feedback on those issues that disqualified these nursing homes. Armed with this information and a look at these members' NHSN data, Nicole Fallon at LeadingAge has also gianed a few other insights that members may find helpful as they attempt to optimize their opportunity to receive remaining incentive payments. 

Nursing homes will recall that the NHIC incentive payment program requires nursing homes to pass both of two gateway criteria to be considered for the incentive payments -- infection control and mortality. To pass the infection control criterion, a nursing home's infection rate per 1000 resident weeks in the performance period must be less than the county's rate of infection per 1000 resident weeks. The mortality criterion excludes facilities that perform below benchmark levels on the rate of mortality among residents with COVID. Facilities with a mortality rate at or above 10% in a given performance period are considered ineligible. LeadingAge has asked for information on the what data is used to calculate the 10% threshold. 

HHS found the following issues for the 70 LeadingAge nursing home members submitted for review, which provide some useful answers and insights into the incentive payments: 

  • 45% of these nursing homes missed the Infection Gateway test. Many of these homes only had one infection but the county infection rate was so low that they would have had to have no infections to qualify.  Also, nursing homes with a lower number of occupied beds have a harder time ensuring their infection rate is less than the county's. Only one nursing home nationally with 2 or more infections received an incentive and they were in a county wtih a high infection rate. 
  • 26% actually received the payment but somehow did not know they had (One of them is still missing a payment). It can be challenging to know what payments are for but the incentive payments typically include the language "HHS NH Payment" somewhere in the language transmitted to the bank. The October incentive payment is scheduled to arrive Dec. 12.
  • 15% were missing at least 1 week of NHSN data or failed NHSN quality assurance. This situation is pretty easy for nursing homes to determine as there is a column that indicates if they have passed the NHSN quality assurance check. Some members discovered that while they submitted their data some fields were not completed. 
  • Another 8% Failed an additional quality assurance check, which means they either:
    • MIssed reporting occupied bed information for one or more weeks. This information is used to calculate the resident weeks number which is used to determine the nursing homes infection rate per 1000 resident weeks. OR
    • They reported more total COVID deaths than total infections, so HHS questioned the validity of the data. Nursing homes should make sure that their total COVID deaths do not exceed the total number of COVID infections reported. This appears to disqualify a nursing home from consideration.
  • One nursing home failed both the infection and mortality gateway.
  • One failed the mortality gateway though it is not clear how as they only had one death in the reporting period and 36 total cases across all weeks reported into NHSN. So, we've asked HHS for clarification.
  • One had their TIN excluded by HRSA from payment. This has occurred for select members in other instances and we were told that they were on the CMS excluded list. When we inquired further, we were told it was because the facility was in bankruptcy.  In cases, where a nursing home is erroneously on this list, they must seek to remedy the situation with either their Medicare Administrative Contractor (MAC) or their CMS regional office. 

For nursing homes interested in understanding why they missed out on an incentive payment or who wish to optimize their chance at future NHIC incentive payments, LeadingAge would recommend they download their data from the NHSN database to see how it compares to what they believe they reported. In most cases, you can determine your eligibility for payments by pulling down your information from the NHSN database and checking for the following items:

  1. Are there any “N”s in the column titled, “data submitted”?
  2. Did you pass the NHSN QA Check for each week of data submitted?
  3. Did you submit data on Total Occupied Beds for all relevant weeks?
  4. Does the data show more Total COVID -19 Deaths (column S) than Total COVID-19 Infections (Column M) (these are the cumulative numbers)? These totals should be cumulative from week to week and not fluctuate up and down. HHS appears to disqualify nursing homes who report more COVID deaths than infections because they view this as invalid data. 
  5. Did you report that testing was unavailable during the performance period (Column Z)?

Also make sure data is entered and completed for all fields for each week during the performance period and 6 weeks prior.

Other insights and considerations: 

  • We've observed the Infection control gateway is impacted by the county infection rate and number of resident weeks. So, it is more challenging to be eligible for incentives if you are in a county with a low infection rate or if you have a low number of occupied beds even if you have only one infection. For example, even a nursing home with 400 plus occupied beds per week and 6 infections over this timeframe was unable to qualify for an incentive because the county rate was so low. In some of these counties the only way to qualify was to have 0 infections during the performance period. 
  • For September, no nursing home with more than 2 cases in the performance period qualified for an incentive. 
  • Resident weeks are the total number of occupied beds reported each of the performance period weeks. These are important because they are used to calculation the infection rate per 1000 resident weeks. 

While providers cannot impact the October incentive payments, at this point, as they have already been calculated and are expected to arrive in nursing home bank accounts on Dec.12, they can better position their organizations for future incentive payments by reviewing their data and correcting any reporting or data issues now.