Version 1.2 Revised 7/20/2025

What is the KPI Reimbursement Report?

The KPI Reimbursement Report represents the quality add-on payments a facility would receive if the next determination was based on its current performance.

What the KPI Reimbursement Report is not:

This report is not intended to serve as a reimbursement calculator.

General Business Rules

State Programs Rules Sources

The calculations are based on documentation from the relevant States as available, augmented by information provided by CHS reimbursement specialists and external consultants. This information will be updated periodically as new rules become available.

Per Diem Add-on Rates

The current per diem add-on rates for the states listed on CHS.Care are as follows:

  • West Virginia: $0.297 per point for each qualifying QM

  • Ohio: $1.20 per point for each qualifying QM

  • Indiana: $0.06 per point for each qualifying QM

  • Maryland: $0.111 per point for each qualifying QM

  • Virginia:

    • Per diem payment rates: 

      • For Hospitalizations

        • 1 point: $3.13

        • 2 points: $4.69

        • 3 points: $6.25

      • For ED Visits

        • 1point: $3.38

        • 2 points: $5.06

        • 3 points: $6.75

      • For Pressure Ulcers 

        • 1 point: $3.13

        • 2 points: $4.69

        • 3 points: $6.25

      • For UTI

        • 1 point: $2.13

        • 2 points: $3.19

        • 3 points: $4.25

      • For Staffing Hours 

        • 1 point: $4.73

        • 2 points: $7.09

        • 3 points: $9.45

Medicaid Days in Period

This report uses the sum of the days of care in the most recent full 12 months for patients whose primary payer on that day is Medicaid (e.g. for the month of July 2024, from July 1, 2023 to June 30, 2024) in PCC.

MDS 3.0 Quality Measures Data Source

MDS 3.0 Quality Measures data are aggregated from DatAlign’s real-time calculations from the MDS assessments submitted to and accepted by the iQIES system. All calculations are made according to the specifications of the MDS 3.0 Quality Measures User’s Manual V17 and have been verified as accurate based on comparison with iQIES Facility and Resident Level QM reports.

Claims Based Measures Data Source

Claims-based measures data is sourced from CMS, with the numerator extrapolated from our calculation of the denominator.

Staffing Data Source

The staffing data is sourced from CMS at this time and will be replaced with real-time data as this becomes available.

Glossary

  • State Rank: Represents the facility’s performance relative to other company facilities in the state based on the QM score.

  • Current Quality Add-on: The annualized sum the facility would receive today based on its current performance were the determination of the next rate made today.

  • Max: The maximum quality add-on the facility could receive with improved performance.

  • Higher: The next highest amount for the quality add-on the facility would receive if its performance improves.

  • Lower: The next highest amount for the quality add-on the facility would receive if its performance worsens.

  • To Max: 

    • For MDS and Hospitalization QMs this represents the number of reductions in events that would lead to receiving the maximum quality add-on value.

    • For Staffing this represents the increase in hours that would lead to receiving the maximum quality add-on value.

    • For Occupancy this represents the additional number of beds that must be occupied per day in the period that would lead to receiving the maximum quality add-on value.

  • To Higher: 

    • For MDS and Hospitalization QMs this represents the number of reductions in events that would lead to an increase in quality add-on.

    • For Staffing this represents the increase in hours that would lead to an increase in quality add-on.

    • For Occupancy this represents the additional number of beds that must be occupied per day in the period that would lead to an increase in quality add-on

  • To Lower: 

    • For MDS and Hospitalization QMs this represents the increase in events that would lead to an decrease in quality add-on

    • For Staffing this represents the decrease in hours that would lead to a decrease in quality add-on.

    • For Occupancy this represents the decrease in the number of occupied beds that would lead to a decrease in quality add-on

  • Lost Revenue: The difference between the maximum quality add-on and the current quality add-on.

  • Cost Per Event: The amount that each incident in the numerator adds to the annual sum the facility would receive.


Version 1.2 Revised 7/20/2025