PBJ: CMS Requiring Closer Accounting of Medical Director Hours
by Karl Steinberg, MD, CMD, HMDC
CALTCM Secretary
 

As of July 1, 2016, the Centers for Medicare and Medicaid Services has been requiring more detailed documentation of employee time spent in nursing homes on the job.  This initiative goes by the tasty acronym of PBJ:  Payroll-Based Journal.  Many of us medical directors have been doing this for awhile, but probably just about all of us will be doing it soon.  Nursing homes in California also now require a specific on-site audit annually to ensure that they meet the state-mandated minimum nursing staffing of 3.2 nurse hours per patient day, but this is a separate matter.

Since nursing facility medical directors are usually not employees of the facility, it could be argued that detailed accounting of time should not be required for independent contractors.  However, CMS has made it clear that this is in fact an expectation for medical directors too.  In the initial policy statement, CMS indicated that only time spent on-site in the facility could be reported.  However, with some input from AMDA and other stakeholders, they modified the statement as follows:

For medical directors, CMS understands it may be difficult to identify the exact hours a physician spends performing medical director activities versus primary care activities. Data reported should be auditable and able to be verified through either payroll, invoices, and/or tied back to a contract. Facilities must use a reasonable methodology for calculating and reporting the number of hours spent on-siteconducting primary responsibilities. For example, if a medical director is contracted for a certain fee (e.g., per month) to participate in Quality Improvement meetings and review a certain number of medical records each month, the facility should have a reasonable methodology for converting those activities into the number of hours paid to work.” (From http://www.paltc.org/publications/cms-releases-updated-pbj-manual-allow-site-medical-director-responsibilities-count)

The responsibility for determining the hours will ultimately fall to the medical director.  Many of us have already been keeping a log of our time performing medical-director duties and including it in our monthly invoice, and this is certainly a best practice—since federal rules require reimbursement based on fair market value.  While clearly not every facility and medical director follow this guidance (e.g., hospitalist medical directors who receive upwards of $5000 monthly while only coming to the facility once every three months for a quality meeting—it’s improbable that $15,000 an hour would be fair market value for work unless you’re a Hollywood star or professional athlete or CEO), those who ignore the law are placing themselves at risk.

Also, keep in mind that time spent doing direct patient care should not be considered in medical director hours—unless it’s on behalf of another provider because of delinquent visits or if another provider is not available, or if asked to participate in IDT meetings, ethics committees, or other evaluations such as wound wounds—and as long as the care is otherwise uncompensated.

Many of us pride ourselves on being engaged medical directors, and bristle when we hear about drive-by medical directors.  We do a lot of things that are not on the clock, including associating our own professional reputations with the facilities we lead, answering the phone 24/7 if something comes up, serving as an emissary of our facilities when we make public appearances or educational presentations, and a whole host of other tasks that go beyond employee physicals and attending QA&A meetings.  To the extent we can, though, we should try to quantify the time we spend inside the building and out—and this will be a requirement for most medical directors nationwide.

So, while yet another paperwork requirement may seem like a drudge, at least there is a sensible reason behind it.  I hope most of us won’t now associate the yummy initials PBJ globally with regulatory hassles and red tape. Since our facilities are expecting us to give them our PBJ hours, it’s only fair that we should be able to request a PBJ as an afternoon snack when we are rounding there once in awhile.

For more discussion on this and other relevant topics, consider joining the Facebook group “PA/LTC Physicians and NP/PAs,” read Caring for the Ages (www.caringfortheages.com), and stay tuned to the Wave.