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A partial payment adjustment will apply if a beneficiary transfers from one HHA to another, or is discharged and readmitted to the same HHA within 30 days of the original 30-day period start date. The adjustment is pro-rated based on the length of the 30-day period ending in transfer or discharge and readmission, resulting in a partial period of payment. Each of the 432 case-mix group has a threshold to determine if the period of care would receive a LUPA.
Agencies that developed a solid PDGM strategy are experiencing fewer problems than agencies who did not. They are learning to address any issues as they occur and are adapting quickly. The elimination of therapy volume as a payment determinant. During this process, the voices of home health agencies and industry players will play a crucial role in how PDGM takes shape and reaches its final version. CMS has weighed in with estimations that PDGM will create both winners and losers, with around 50% of homecare agencies experiencing an increase in reimbursements and the other 50% weathering lowered reimbursement rates. Home Health Care News is the leading source for news and information covering the home health industry.
When did PDGM go into effect?
It is not guaranteed that this will occur during the PDGM implementation, but providers should be aware of the potential delays. Finally, National Association for Home Care & Hospice performed an independent review using example cases for PDGM periods starting on various dates. This analysis found that in most cases agency cash flow would not return to pre-PDGM levels until approximately March 2020. The impact will be different for each provider, but our recommendation is that providers prepare for this potential risk. PDGM changes the method for calculating payments, including the changing of 60 day episode payments to 30 day payment periods and the removal of the therapy thresholds. PDGM will change the payment rates for agencies as compared to our current PPS model.
There has been no indication that the processing time for RAPs will change under PDGM. We recommend, however, that providers monitor processing times over the first couple months of 2020 in case the RAP processing time is impacted by updates made to the Medicare system for PDGM. CMS announced that the final behavior change adjustment for PDGM 30-day payment rates would be a 4.36% reduction instead of the proposed 8.01% decline. The largest change facing home health agencies in over two decades has many organizations evaluating and updating internal processes. Others are expanding their service lines to serve more clinically complex patients.
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New LUPA thresholds that vary by HHRG, based on the 30- day period of care. One of the things we see often in documentation is therapy driven goals. Therapists and agencies would do well to listen to patients and develop goals together.
As PDGM was rolled out and explained, many were understandably concerned with therapy and PDGM. There was concern about job losses, reduced pay, reduced work, layoffs, bankruptcies, and everything in between. A federal government website managed and paid for by the U.S. A .gov website belongs to an official government organization in the United States.
Patient-Driven Groupings Model Toolkit
Within the current system, home health providers receive a LUPA claim for providing 4 or less visits over 60-day care episodes within any category of patient delivered care. Providers then in turn only get a standardized per-visit payment, no matter the cause for fewer recorded visits. The new PDGM rules will effectively transform that universal four-or-fewer rule and morphs it into 216 differing scenarios. In consequence, estimated LUPA rates are expected to fall from 8% to 7.1% once PDGM takes effect, with scattered predictions that they may increase.
Typically, CMS releases its proposed payment rule in late June or early July. With two years of PDGM observations and the public health emergency starting to wane, the agency may float big adjustments at that time. Home health care agencies are challenged to develop and implement a plan to meet all the requirements of PDGM and optimize reimbursement. Relias has the tools that can help you properly train your staff, standardize your processes, and manage your staff’s development. CMS sees this as a problem because they want organizations to treat the patient, instead of trying prescribe a treatment that will maximize dollars. To take a proactive stance against this behavior, CMS reduces the amount of money given for certain reimbursements.
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This threshold is determined by the tenth percentile of visits in each payment group with a minimum of threshold of 2. Two admission source categories used for grouping a 30-day period of care. FISS will be modified to auto-cancel RAP payments on or after January 1, 2020 when the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP.
Coding and OASIS were derived to develop an effective score to show through data the condition of the patient at the time of assessment. To avoid LUPA there needed to be more than 4 and to stay under the radar, less than 20 therapy visits. Anything in between would not normally raise many questions. Naturally, many home health agencies and therapists would then provide as much therapy as possible in order to increase revenue for both the agency and therapist.
We also help make sure that accurate data is sent to CMS to ensure that potential adjustments and tweaks are based on good data. HHA providers newly enrolled in Medicare on or after January 1, 2019, submit a no-pay RAP and one final claim for each 30 day period. Nurses absolutely can document and send to physician to verify what the nurse documents or if something isn't found in an History and Physical summary. If a diagnosis isn't relevant to a physician, they may not document it, but it could certainly impact the care and outcome of a patient.
CMS states that these are too vague and they don’t provide enough information to support the need for home health services. Claims that have unacceptable primary diagnoses will be “returned to provider” because CMS cannot assign the 30-day period to a clinical group for payment. Cutting payment periods in half, from 60-day episodes to 30-day periods of care.
Providers will have to adapt the use of the existing MSP billing codes to the new PDGM claim format. Relias helps healthcare leaders, human service providers, and their staff take better care of people, lower costs, reduce risk, and achieve better results. Home Health providers need to be proactive in identifying the impact as well as planning how to change operations to fit the new PDGM model.
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