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| SKH > SEC Filings for SKH > Form 10-Q on 5-Nov-2012 | All Recent SEC Filings |
5-Nov-2012
Quarterly Report
The prior period financial statements included in this filing have been revised to reflect the correction of the aforementioned errors, see Note 2 - "Correction of Previously Issued Consolidated Financial Statements," to our Condensed Consolidated Financial Statements included in Item 1 for additional information on these revisions. The condensed consolidated statement of operations for the quarter ended March 31, 2012 has not been restated. Revenue for the quarter ended March 31, 2012 was overstated by $0.3 million. This correction has been recorded as an adjustment to revenue in the quarter ended June 30, 2012, as this amount was not material to the operating results for the period then ended. Despite the fact that our affected subsidiaries have refunded all of the reimbursements they received in connection with the Medicare Part B claims for all blood glucose tests after January 1, 2007, some refunded claims could nonetheless potentially lead to allegations that any of the affected subsidiaries are subject to sanctions under the Federal False Claims Act or the Federal Civil Monetary Penalties Law. Such sanctions could lead to any combination of a variety of criminal, civil and administrative penalties, which could be material both individually and in the aggregate. We cannot determine the likelihood that any penalties might be imposed related to this refund and have not accrued for any such penalties. See "Revenue we receive from Medicare and Medicaid is subject to potential retroactive reduction or repayment" in Part II, Item 1A of this report for additional information.
Industry Trends
Medicare and Medicaid Reimbursement
Rising healthcare costs due to a variety of factors, including an aging
population and increasing life expectancies, has in recent years increased
demand for post-acute healthcare services, such as skilled nursing, assisted
living, home health care, hospice care and rehabilitation therapy. In an effort
to mitigate the cost of providing healthcare benefits, third party payors
including Medicare, Medicaid, managed care providers, insurance companies and
others have increasingly encouraged the treatment of patients in lower-cost care
settings. As a result, in recent years skilled nursing facilities, which
typically have significantly lower cost structures than acute care hospitals and
certain other post-acute care settings, have generally been serving larger
populations of higher-acuity patients than in the past. Despite this growth in
demand, uncertainty over Medicare and Medicaid reimbursement rates persists.
Medicare and Medicaid reimbursement rates are subject to change from time to
time and, because revenue derived directly or indirectly from Medicare and
Medicaid reimbursement has historically comprised the most significant portion
of our consolidated revenue, a reduction in rates could materially and adversely
impact our revenue.
Medicare reimburses our skilled nursing facilities under a prospective payment
system ("PPS") for certain inpatient covered services. Under the PPS, facilities
are paid a predetermined amount per patient, per day, based on the anticipated
costs of treating patients. The amount to be paid is determined by classifying
each patient into a resource utilization group ("RUG") category that is based
upon each patient's acuity level. In October 2010, the number of RUG categories
was expanded from 53 to 66 as part of the implementation of the RUGs IV system
and the introduction of a revised and substantially expanded patient assessment
tool called the minimum data set (MDS) version 3.0.
On July 29, 2011, the Centers for Medicare & Medicaid Services ("CMS") issued a
final rule providing for, among other things, a net 11.1% reduction in PPS
payments to skilled nursing facilities for CMS's fiscal year 2012 (which began
October 1, 2011) as compared to PPS payments in CMS's fiscal year 2011 (which
ended September 30, 2011). The 11.1% reduction was on a net basis, after the
application of a 2.7% market basket increase, and reduced by a 1.0% multi-factor
productivity adjustment required by the Patient Protection and Affordable Care
Act of 2010 ("PPACA"). The final CMS rule also adjusted the method by which
group therapy is counted for reimbursement purposes, and changed the timing in
which patients who are receiving therapy must be reassessed for purposes of
determining their RUG category.
The Middle Class Tax Relief and Job Creation Act of 2012 was signed into law on
February 22, 2012, extending the Medicare Part B outpatient therapy cap
exceptions process through December 31, 2012. The statutory Medicare Part B
outpatient therapy cap for occupational therapy (OT) is $1,880 for 2012, and the
combined cap for physical therapy (PT) and speech-language pathology services
(SLP) is also $1,880 for 2012. This is the annual per beneficiary therapy cap
amount determined for each calendar year. Similar to the therapy cap, Congress
established a threshold of $3,700 for PT and SLP services combined and another
threshold of $3,700 for OT services. All therapy services rendered above the
$3,700 are subject to manual medical review and certain providers will be
required to submit a request for an exception. The law requires an exceptions
process to the therapy cap that allows providers to receive payment from
Medicare for medically necessary therapy services above the therapy cap amount.
Beginning October 1, 2012 some therapy providers are required to submit
requests for exceptions (pre-approval for up to 20 therapy treatment days for
beneficiaries at or above the $3,700 threshold). The $3,700 figure is the
defined threshold that triggers the requirement for an exception request. Prior
to October 1, 2012 there was no requirement for an exception request when the
threshold was exceeded. We expect the Medicare Part B therapy cap exception
requirements that went into effect October 1, 2012 to negatively impact our
therapy business in the fourth quarter of 2012.
On July 27, 2012, CMS issued a final rule providing for, among other things, a
net 1.8% increase in PPS payments to skilled nursing facilities for CMS's fiscal
year 2013 (which begins October 1, 2012) as compared to PPS payments in CMS's
fiscal year 2012 (which ends September 30, 2012). The 1.8% increase was on a net
basis, after the application of a 2.5% market basket increase, and reduced by a
0.7% multi-factor productivity adjustment required by PPACA. After our wage
index adjustment, our net increase was 1.7%.
In July 2012, CMS issued its final rule for hospice services for its 2013 fiscal
year. The rule includes a market basket increase of 2.6% less 0.3% reduction in
the market basket as a result of the PPACA and a 0.7% reduction due to
productivity adjustment. After adjusting for the wage index in our hospice
agencies, we estimate that the net impact on our hospice service operations will
be an increase of 0.9% in our reimbursement rates effective October 1, 2012.
Should future changes in PPS include further reduced rates or increased
standards for reaching certain reimbursement levels (including as a result of
automatic cuts tied to federal deficit cut efforts or otherwise), our Medicare
revenues derived from our skilled nursing facilities (including rehabilitation
therapy services provided at our skilled nursing facilities) could be reduced,
with a corresponding adverse impact on our financial condition and results of
operation. Our rehabilitation therapy, hospice and home health care businesses
are also to a large degree directly or indirectly dependent on (and therefore
affected by changes in) Medicare and Medicaid reimbursement rates. For example,
our rehabilitation therapy business may have difficulty increasing or
maintaining the rates it has negotiated with third party nursing facilities in
light of the reduced PPS reimbursement rates that took effect on October 1, 2011
as discussed above or future reductions in reimbursement rates.
We also derive a substantial portion of our consolidated revenue from Medicaid
reimbursement, primarily through our skilled nursing business. Medicaid programs
are administered by the applicable states and financed by both state and federal
funds. Medicaid spending nationally has increased substantially in recent years,
becoming an increasingly significant component of state budgets. This, combined
with slower state revenue growth and other state budget demands, has led both
the federal government and many states, including California and other states in
which we operate, to institute measures aimed at controlling the growth of
Medicaid spending (and in some instances reducing it).
Historically, adjustments to reimbursement under Medicare and Medicaid have had
a significant effect on our revenue and results of operations. Recently enacted,
pending and proposed legislation and administrative rulemaking at the federal
and state levels could have similar effects on our business. Efforts to impose
reduced reimbursement rates, greater discounts and more stringent cost controls
by government and other payors are expected to continue for the foreseeable
future and could adversely affect our business, financial condition and results
of operations. Additionally, any delay or default by the federal or state
governments in making Medicare and/or Medicaid reimbursement payments could
materially and adversely affect our business, financial condition and results of
operations.
Federal Health Care Reform
In addition to the matters described above affecting Medicare and Medicaid
participating providers, PPACA enacted several reforms with respect to skilled
nursing facilities, home health agencies and hospices, including payment
measures to realize significant savings of federal and state funds by deterring
and prosecuting fraud and abuse in both the Medicare and Medicaid programs.
While many of the provisions of PPACA will not take effect for several years or
are subject to further refinement through the promulgation of regulations, some
key provisions of PPACA are presently effective.
• Enhanced CMPs and Escrow Provisions. PPACA includes expanded civil
monetary penalty ("CMP") and related provisions applicable to all
Medicare and Medicaid providers. CMS rules adopted to implement
applicable provisions of PPACA also provide that assessed CMPs may
be collected and placed in whole or in part into an escrow pending
final disposition of the applicable administrative and judicial
appeals processes. To the extent our businesses are assessed large
CMPs that are collected and placed into an escrow account pending
lengthy appeals, such actions could adversely affect our results of
operations.
• Nursing Home Transparency Requirements. In addition to expanded CMP
provisions, PPACA imposes new transparency requirements for
Medicare-participating nursing facilities. In addition to previously
required disclosures regarding a facility's owners, management and
secured creditors, PPACA expanded the required disclosures to
include information regarding the facility's organizational
structure, additional information on officers, directors, trustees
and "managing employees" of the facility (including their names,
titles, and start dates of services), and information regarding
certain parties affiliated with the facility. The transparency
provisions could result in the potential for greater government
scrutiny and oversight of the ownership and investment structure for
skilled nursing facilities, as well as more extensive disclosure of
entities and individuals that comprise part of skilled nursing
facilities' ownership and management structure.
• Face-to-Face Encounter Requirements. PPACA imposes new patient
face-to-face encounter requirements on home health agencies and
hospices to establish a patient's ongoing eligibility for Medicare
home health services or hospice services, as applicable. A
certifying physician or other designated health care professional
must conduct the face-to-face encounters within specified
timeframes, and failure of the face-to-face encounter to occur and
be properly documented during the applicable timeframes could render
the patient's care ineligible for reimbursement under Medicare.
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• Suspension of Payments During Pending Fraud Investigations. PPACA
provides the federal government with expanded authority to suspend
Medicare and Medicaid payments if a provider is investigated for
allegations or issues of fraud. This suspension authority creates a
new mechanism for the federal government to suspend both Medicare
and Medicaid payments for allegations of fraud, independent of
whether a state exercises its authority to suspend Medicaid payments
pending a fraud investigation. To the extent the suspension of
payments provision is applied to one of our businesses for
allegations of fraud, such a suspension could adversely affect our
results of operations.
• Overpayment Reporting and Repayment; Expanded False Claims Act
Liability. PPACA enacted several important changes that expand
potential liability under the federal False Claims Act. Overpayments
related to services provided to both Medicare and Medicaid
beneficiaries must be reported and returned to the applicable payor
within specified deadlines, or else they are considered obligations
of the provider for purposes of the federal False Claims Act. This
new provision substantially tightens the repayment and reporting
requirements generally associated with operations of health care
providers to avoid False Claims Act exposure.
• Home and Community Based Services. PPACA provides that states can
provide home and community-based attendant services and supports
through the Community First Choice State plan option. States
choosing to provide home and community based services under this
option must make them available to assist with activities of daily
living, instrumental activities of daily living and health related
tasks under a plan of care agreed upon by the individual and his/her
representative. For states that elect to make coverage of home and
community-based services available through the Community First
Choice State plan option, the percentage of the state's Medicaid
expenses paid by the federal government will increase by 6
percentage points. PPACA also includes additional measures related
to the expansion of community and home based services and authorizes
states to expand coverage of community and home-based services to
individuals who would not otherwise be eligible for them. The
expansion of home-and-community based services could reduce the
demand for the facility based services that we provide.
• Health Care-Acquired Conditions. PPACA provides that the Secretary
of Health and Human Services must prohibit payments to states for
any amounts expended for providing medical assistance for certain
medical conditions acquired during the patient's receipt of health
care services. CMS adopted a final rule to implement this provision
of PPACA in the third quarter of 2011. The rule prohibits states
from making payments to providers under the Medicaid program for
conditions that are deemed to be reasonably preventable. It uses
Medicare's list of preventable conditions in inpatient hospital
settings as the base (adjusted for the differences in the Medicare
and Medicaid populations) and provides states the flexibility to
identify additional preventable conditions and settings for which
Medicaid payment will be denied.
• Value-Based Purchasing. PPACA requires the Secretary of Health and
Human Services to develop a plan to implement a value-based
purchasing ("VBP") program for payments under the Medicare program
for skilled nursing facilities and to submit a report containing the
plan to Congress. The intent of the provision is to potentially
reconfigure how Medicare pays for health care services, moving the
program towards rewarding better value, outcomes, and innovations,
instead of volume. According to the plan submitted to Congress in
June 2012, the funding for the VBP program could come from payment
withholds from poor-performing skilled nursing facilities or by
holding back a portion of the base payment rate or the annual update
for all skilled nursing facilities. If a VBP program is ultimately
implemented, it is uncertain what effect it would have upon skilled
nursing facilities, but its funding or other provisions could
negatively affect skilled nursing facilities.
• Anti-Kickback Statute Amendments. PPACA amended the Anti-Kickback
Statute so that (i) a claim that includes items or services
violating the Anti-Kickback Statute also would constitute a false or
fraudulent claim under the federal False Claims Act and (ii) the
intent required to violate the Anti-Kickback Statute is lowered such
that a person need not have actual knowledge or specific intent to
violate the Anti-Kickback Statute in order for a violation to be
deemed to have occurred. These modifications of the Anti-Kickback
Statute could expose us to greater risk of inadvertent violations of
the statute and to related liability under the federal False Claims
Act.
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The provisions of PPACA discussed above are examples of recently enacted federal health reform provisions that we believe may have a material impact on the long-term care profession generally and on our business. However, the foregoing discussion is not intended to constitute, nor does it constitute, an exhaustive review and discussion of PPACA. It is possible that other provisions of PPACA may be interpreted, clarified, or applied to our businesses in a way that could have a material adverse impact on our business, financial condition and results of operations. Similar federal and/or state legislation that may be adopted in the future could have similar effects.
Revenue
Revenue by Service Offering
We operate our business in three reportable operating segments: (i) long-term
care services, which includes the operation of skilled nursing and assisted
living facilities and is the most significant portion of our business; (ii) our
rehabilitation therapy services business; and (iii) our hospice and home health
businesses. Our reporting segments are business units that offer different
services, and that are managed separately due to the nature of services
provided.
In our long-term care services segment, we derive the majority of our revenue by
providing skilled nursing care and integrated rehabilitation therapy services to
residents in our affiliated skilled nursing facilities. The remainder of our
long-term care segment revenue is generated by our assisted living facilities,
by our administration of an unaffiliated third party skilled nursing facility,
and from our leasing of five skilled nursing facilities to an unaffiliated third
party operator. In our therapy services segment, we derive revenue by providing
rehabilitation therapy services to third-party facilities. In our hospice and
home health services segment, we provide hospice and home health services.
The following table shows the revenue and percentage of our total revenue
generated by each of these segments for the periods presented (dollars in
thousands):
Three Months Ended September 30,
2012 2011
Revenue Revenue Revenue Revenue Increase/(Decrease)
Dollars Percentage Dollars Percentage Dollars Percentage
Long-term care
services:
Skilled nursing
facilities $ 156,550 72.3 % $ 164,140 75.8 % $ (7,590 ) (4.6 )%
Assisted living
facilities 7,133 3.3 7,021 3.2 112 1.6
Administration of
third party
facility 132 0.1 309 0.1 (177 ) (57.3 )
Facility lease
revenue 769 0.3 746 0.3 23 3.1
Total long-term
care services 164,584 76.0 172,216 79.4 (7,632 ) (4.4 )
Therapy services:
Third-party
rehabilitation
therapy services 26,161 12.1 23,158 10.7 3,003 13.0
. . .
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