The cost of payroll-based journal reporting adding up fast

For the past year, skilled nursing facilities have been aware of pending new regulations from the Centers for Medicare & Medicaid Services (CMS). Facilities are required to electronically submit detailed direct-care staffing information, with the intent of linking those staffing records to the CMS’ five-star rating system. When the first quarterly reporting period for the Payroll-Based Journal (PBJ) program began July 1, long-term, post-acute care  providers have woken up to the realization that meeting the requirement is more difficult and time-consuming than originally thought. As a result, many have turned to the vendors of time-and-attendance software and other solution providers for help.

For several years, CMS has gathered staffing data to gauge impact on quality of care in nursing homes. The data, when combined with census information, can be used to report on the level of staff, employee turnover and tenure, which can impact the quality of care delivered. But there was concern that the system of collecting this data through self-reporting and surveys was too easy for SNFs to “game,” so PBJ was created as a more transparent and auditable source of workforce data.

So how difficult are facilities finding the transition to PBJ compliance? “It is a big change,” says Peter Corless, executive vice president of enterprise development for OnShift, a Cleveland-based workforce software-as-a-service provider focused on long-term care and senior living.

Data collection

Previously, a surveyor would come on-site annually and ask the facility to indicate staff hours worked in the previous biweekly pay period — and that will still happen, he says. But the PBJ reporting asks for additional information about employee tenure and contractors and agency personnel that previously wasn’t required.

That’s where it becomes more difficult, Corless says. Hourly employees are logged in a time-and-attendance system and a payroll system. Between the two you can get some of the information required. But typically, salaried employee data are not typically stored there. Often, services such as physical therapy are outsourced and those workers’ information is not in a timekeeping system. All that employee data must now be collected and aggregated somehow from those outsourced partners or entered manually for PBJ purposes.

Carl Moellenkamp, CPA, is the director of consulting in the healthcare division of professional services firm CliftonLarsonAllen LLP. He says many people believe they are moving forward with PBJ, but the groups he has worked with closely are recognizing there are a lot of moving pieces that are going to take a lot of time to figure out. For instance, the hours of an employee who works an 11 p.m. – 7 a.m. shift must be reported on the calendar day worked rather than just summarized. “And having to pull data from multiple sources is causing a lot of our clients to say this is a bigger challenge than they thought it was going to be initially,” he says.

There are a whole host of concerns, says Cheryl Phillips, MD, LeadingAge’s senior vice president for public policy and health services. Staff members for smaller providers are often “multi-duty” in their assignments. For instance, a director of nursing might also be the infection control nurse. They are grappling with how to report that, and there is great confusion regarding on-site contract staff. “We continue to receive numerous questions from our provider members and few answers from CMS,” Phillips says.

One interesting nuance, Moellenkamp says, is that although this is called Payroll-Based Journal entry, the data doesn’t typically reside in much detail in a payroll system. The data resides in a time-and-attendance system. A lot of information in payroll systems is summarized already and not as useful for PBJ purposes.

Elaine Howell, a workforce solutions consultant at workforce management software company Kronos Inc., agrees with Moellenkamp that providers really only need data from time-keeping systems. “When you get deep into the policy, it is about where they were worked and were they providing direct care or not. Payroll does not look at the daily information, which is what PBJ is all about,” she says.

There are two aspects to compliance:

1. aggregating the data and
2. successfully reporting to CMS regularly. 

Some vendors have popped up with subscription-based services to help facilities with the second aspect.

A new company called ezPBJ imports, converts and maps vendor-provided files to the PBJ specifications and include them in a single PBJ submission file. Don Feigle, ezPBJ’s CEO, says there is something of a learning curve to understanding the policy and quirks of the way data has to be set up. ”But we think we have it down to where it is going to be a handful of hours every quarter to take care of this for them.”

The company SimpleLTC, which built a business helping nursing facilities report Minimum Data Set (MDS) files to CMS, has added a PBJ reporting solution as well. It does not help customers with data aggregation or policies. But it does simplify the process of getting data to and from CMS, says Jason Jones, the company’s chief technology officer. “We are kind of like Federal Express,” he says. “We don’t put the stuff in the box. We just guarantee that it gets there.”

Others, like Kronos, developed a PBJ Link tool in its interface so providers can convert workforce management data to the appropriate format for CMS reporting, she says. “This is simply an extraction of the information that is in our system, but formatting it differently than how you pay your employees,” Howell explains.

Contractor information a challenge

Jones says the No. 1 implementation challenge he has heard from customers is how to get the data about contractors into the system. “What is emerging as the cleanest way to do this is to develop one internal data store where you are pulling in aggregated contractor data,” he says. Some workforce management solution vendors recommend facilities require contract workers to use a time clock, even though that data will not be sent to payroll, he says. “But I have heard that physical therapists are resistant to punching a time clock. Some of it is just cultural.”

Beth Baerman, compliance specialist and director of communications for Attendance on Demand, a cloud-based workforce management solution, says there are basically three options for SNFs dealing with contractor agency staff:

1. Hope the agency or contractor is tracking the employees’ time and can give SNFs a file with that information. “That is probably not going to happen,” she says.
2. Add those contractors into their timekeeping system but not send that information to payroll.
3. Manually enter data for contract employees, a time-consuming process.

The most cost-effective way is to add them into timekeeping with the information not going to payroll, Baerman says.

She says following the changes at CMS regarding PBJ has been a high priority for Attendance on Demand. “We are keeping up with changes,” she says. “As with any new regulation, there will be modifications. We already know there are a number of things advocacy groups will be challenging, so we expect there will be more changes coming.”

Voluntary reporting period

CMS has been collecting staffing and census data through the PBJ system on a voluntary basis since Oct. 1, 2015, but only a small percentage of facilities opted to participate.

SimpleLTC’s Jones says of the 2,500 facilities that use his company’s CMS transmission product for MDS, only about 200 used it to participate in the test period. “A very low percentage really embraced it early on, but more are rushing in with interest at the end,” he says. “Larger, more sophisticated customers were on this a year ago, but most just started in the last few months. We did a webinar on this topic and asked attenees how prepared they felt for PBJ. Only 1 percent said they felt prepared.”

OnShift’s Corless says after several months of the voluntary reporting period, only 1 percent of SNFs registered to participate. “They were presuming it would be delayed or go away,” he says. The requirement had been delayed once, he notes, when CMS realized it was going to be more complicated than originally thought. But in 2014 when the Impact Act was passed, they appropriated another $11 million to continue development. CMS was not going to delay again.

With CMS’ intent clear, there has been a flurry of activity by providers to catch up.  Now 50 percent have signed up to submit, Corless says. “What CMS is not saying is how many have had successful submissions. It is one thing to sign up, and another to get successful submission through the QIES (Quality Improvement and Evaluation System) and then go back into the CASPER (Certification and Survey Provider Enhanced Reports) system to see if submission was accepted or not.”

Corless says although most providers understand the logic behind the PBJ requirement from CMS’ perspective, they also see it as an unfunded mandate. “They view it as being burdensome because it is complicated. And there are questions of how ‘apples to apples’ the comparison will be because there are still shades of gray in terms of interpretation. CMS has fielded thousands of questions from people trying to get clarification about things they had never thought of.”

Philadelphia-based David Raths is senior contributing editor for Long-Term Living's sister-brand, Healthcare Informatics. He can be reached at draths@mac.com.

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