LASA PANEL: LEGITIMATE CARE OR SHARP PRACTICE – WHAT IS REALLY GOING ON WITH ACFI CLAIMS?

There has been much in the media in recent months regarding the Aged Care industry; accusations of rorting, profiteering and over-claiming of the Aged Care Funding Instrument (ACFI). This was ignited by Aged Care Minister Sussan Ley and the Commonwealth stating that there is a ‘concerning number’ of false claims and ‘unaccounted growth’ in complex health care spending. So, what is really going on with ACFI Claims?

This topic was a focus of the recent LASA Panel held on 8th March 2016. I was lucky enough to be invited to sit on the panel of experts to discuss the facts and fallacies surrounding ACFI Claims where we discussed:

  • The facts behind claiming for Complex Health Care (CHC)
  • The evidence behind the increase in claims in the CHC domain
  • Recommendations to alleviate the financial impact of the July 1 changes.

ARE AGED CARE PROVIDERS AND CONSULTANTS OVER-CLAIMING ON THE CHC DOMAIN?

The evidence that the Commonwealth has used to back their claims does not take into account factors such as actual cost of care and rising care needs. Utilising MyVitals (over 80,000 beds worth of current and historical ACFI data), we can see that the Commonwealth’s reference to statistics isn’t quite accurate. Based on data of missed funding from over 45% of the industry, the evidence suggests that the vast majority of providers are in fact UNDER-CLAIMING; not over-claiming as the Commonwealth has insinuated. The Commonwealth’s blanket statement that the CHC domain has risen triple the rate of the activities of daily living (ADL) and Behaviour domains needs further investigation, as this is not strictly true! MyVitals data shows high care facilities claiming patterns across the domains has been relatively stable over the past 12 months. Within Ageing in Place facilities, residents with High level claims in ADLs increased 6.1%, High level in Behaviours 3.8% and High level CHC claims by 10.8%.

So, where is all the action? Ageing in Place facilities!

High Care vs Ageing in place

Over 2015, the MyVitals data ACFI average for high care moved from $170 to $174 (only a 2.3% increase) but the AIP average has shifted from $142 to $157 (10.6% increase). Why is this so? Because the residents are… ageing in place! Their needs for support are increasing over time, and as they do the funding rightly increases, to sustain the rising cost of the care.

The Commonwealth is highlighting the imbalance of CHC claims over the other domains. Why has there been such a sharp increase in claims in this domain? Is there really an imbalance? The answer is ‘No’. Instead, we propose there has been a correction in the imbalance.

  • 12 months ago, CHC High level claims were the lowest of the three domains. Only very recently have CHC High level claims moved closer to the Behaviour domain. However, it still is the lowest listed domain in High level claims.
  • More and more physical function assessments are being conducted by Physios, whose expertise falls in the CHC domain.
  • Chronic and complex pain identification and management expertise has been growing since the Commonwealth release of the Pain Management Guidelines (PMG) in 2013.

The Commonwealth has drawn the conclusion from the increase in CHC Domain claims that the industry has made excessive or exaggerated claims. The Aged Care industry supports strict guidelines and stringent assessment criteria for ACFI claiming and we suggest that tightening the criteria should be a first step if this is considered an issue. However, the conclusion drawn from the Commonwealth has instead led to funding cuts to the CHC Domain. This reaction does not reduce the numbers of residents with CHC claims, which is the crux of the ‘issue’; but instead becomes a financial decision that does not consider the data nor other various factors behind the increase.

WHAT DOES THIS ALL MEAN?

The increase in CHC Domain funding claims can be attributed to many factors, other than the conclusion the Commonwealth has drawn. Older Australians are living longer, with care needs increasing over time and the complexity surrounding the CHC domain has been mystified, bringing CHC claims more in line with the other domains. The industry is rightly, and in the majority of cases, correctly maximising funding for the care of their residents.

WHAT CAN WE DO TO MITIGATE THE FINANCIAL IMPACT OF THE IMPENDING JULY 1 CHANGES?

Recommendations:

    1. Ensure you are receiving your full ACFI entitlement – Providers can no longer afford to under-claim on any single resident.
    2. Sort out your ACFI by 30 June – Validation of these residents post 1 July will be on current rules and funding claimed.
    3. Get your 4b claims in order. At Provider Assist, we utilise physios with RNs for every re-appraisal and on average we find that between 20% and 30% of residents require 4b treatments with around 60% requiring 4A treatments. If you are well outside that range, you may be over-stating your 4B claims. This is certainly going to be an area of reduced funding so be sure you are not too reliant on 4b claims post July.
    4. Ensure you are conducting Comprehensive assessments that are congruent with your care plans and care plans are being followed by your nursing and PCA staff. Validators will be delving deeper so ensure that you are providing the right care.
    5. Don’t let the over-claiming measures scare you into providing less care – your residents have the right to proper care and maximised funding. If you are doing the right thing but making accidental errors, you will not be fined.
    6. Validators are going to apply more pressure than ever but that doesn’t mean they cannot make mistakes, and you have a right to question decisions made. In the past 12 months Provider Assist has conducted approximately 2,000 voluntary re-appraisals with only 2 downgrades! We assisted providers in challenging a further 10 ACFI downgrades through the appeal process and had the decisions overturned on all 10.

We are here to help so if you have any questions about any of the above or anything aged care; please contact us on 1300 419 119 or team@providerassist.com.au

 

WHAT ARE OTHER REASONS THAT COULD BE BEHIND THE INCREASE IN CHC CLAIMS?

Kelly Peter Watson – Founder and Managing Director
Author

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